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VOLUME XXVIII.

®^l^ llptcian anlr ^m^m

A PROFESSIONAL MEDICAL JOURNAL.

BDITBU BT

JOHN WILLIAM KEATING, M. I).

WITH THB COLLABORATION OF

GBOBGE DOCK, M. D.

REUBEN PETERSON, Iff. D.

ALDRED BCX>TT WARTHIN. M. D.

WALTER ROBERT PARKER, M D.
FRANK BANGHART WALKER, M. D.
ALBERT MOORE BARRBTT, M. D.
R. BISHOP OANFIELD. M. D.
WILLIAM FLEMING BRBAKET. M. D
WILLIS SIDNEY ANDERSON, M. D.
VERNON JUSTIN WILLEY, M. A.
WILLIAM HORACE MORLEY. M. D.
IRWIN HOFFMAN NEFF, M. D.

DEL08 LEONARD PARKER, M. D.
OYRENUS GARRITT DARLING, M. D.
DAVID MURRAY COWIE, M. D.
IRA DEAN LOREE, M. D.
JAMES FLEMING BREAKEY, M. D.
CARISTOPHER GREGG PARNALL, M. D.
GUY UNCOLN KIEFER, M. D.
MARSHALL LAWRENCE CUSHMAN. M, D.
LOUIS JACOB HIR8CHMAN, M. D.
ARTHUR DAVID HOLMES, M. D.
ROLLAND PARMETER. M. D.
DAVID INGLIS, M. D.

JANUARY TO DECEMBER.

COPYRIGHTED

Founded bt JOHN WILLIAM KEATING. M. D., January, 1879

DETROIT AND ANN AKBOR,

MICHIGAN.

1900

AUTHORS.

Anderson, Willis S., 31, 82, 133,
225, 26s, 320, 364,
Akonstam, Noah £., .
Barhbtt, Albert M., .
Benn, Walter J., .
Blodgett, William E.,
BoDiNE, John A., 18, 21, 22, 74,
Bradley, Ernest B., .
Breakey, James P., 135, 227, 267,
Breakey, William F.,
Canfield, R. Bishop, 30, 80, 224,
Caulkins, John S., 118. 245, 302,
Chetwood, Charles H.,
Child, Charles G., Jr.,
Collins, Alvah N., .
Cook, Anna Marion, .
CowiE, David M., 128, 173,
Cushman, Marshall L., 363,
Darling, Cyrenus G., 24. 129,

Dawbarn, Robert H. M., .
de Nancrede, Charles B. G.,
Dock, George, 23, 65, 75, 413, 470,
Edgerton, Joseph I., .
Freund, Hugo A., 389,

FuLD, Joseph E.,
Gates, Neil A., .
Grosh, Lawrence L..
HiRSCHMAN, Louis J., 83, 134, 179,
' 320, 36s,
Holmes, Arthur D., 27, 77, 133,
221. 317, 361,
Keller, Frederick C,
Keyes, Edward L., Jr.,
Klingmann, Thbophil,
Knapp, Don D., .

218, 289,

219,
313,

Page.

178,

409» 507

. 492

. 563

• 3"

97, 400

125, 127
. 536

3^, 510
.32, 385

465, 471

351, 396
. 74
. 127
. 208
289
I, 446

506, 561

257,

458, 500

. 49

481, 557
. 170

446, 469

20, 217

. 250

. 529
266,

4", 510
177,
406, 504

. 125

. 168
68,558

. 560

Kuhn, Charles F.,

Ladinski, Louis J.,

Larkin John H.,

LoREE. Ira D., 28, 78, i

Lyle, Alexander,

Lyman, William R.,

Miller, Paul S.,

Morley, William H.

McGraw, Theodore A

McKee, Edward S.,

Neff, Irwin H., 35, 62, 84, 136,

268, 321, 37^. 412,
Parker, Delos L., 36, 85, 229, 323,
Parker, Walter R., . 29, 79,
Parmeter, Rolland, .
Parnall, Christopher G., 25, 66,

131, 176, 315. 360,
Pedersen, Victor C, .
Peterson, Reuben,
Porter, Miles F.,
Robinson, Andrew R.,
Signor, Wales Melvin,
Sinclair, Daniel A., .
Slocum, George,
Smithies, Frank,
SoLis, Jeanne C,
Taylor, Joseph C,
Vaughan, Victor C, .
Walker, Frank Banghart, 76,

241
Wallace, James B.,
Warthin, Aldred S.,
WiLLEY, Vernon J.,
Wyman, Hal C,
Yeomans, Frank C,

Page.

. 164

. 217

319, 407
126, 215

• 255
. 343
26, 113
. 13
. 494
228,

488, 513
372, 514
224, 497
. 404
. 76,
403. 502

214. 215

461, 499
. i6q

145, 433

47, 316
. 171
. 337
. 467
. 564
. 123
I

173,

259, 402
. 121
. 544

193, 512
. 200
. 215

ARTICLES.

Abdominal section, preoperative treatment
for, 433.

Abortion, treatment of, 76.

Abscess, inferior retropharyngeal, follow-
ing the removal of adenoids in an adult,

507.
Actinomycosis of the neck, 365.
Adenoids, 255.

in an adult, inferior retropharyngeal

abscess following the removal of, 507.

Alimentary canal, rythmic sounds of the,

128.
Anesthesia in rectal surgery, 266.
in the first stage of labor, 316.
steiile water, in operative treatment of
diseases of rectum and anus, 510.
Anesthetic aid, scopolamine as an, 76.
Aneurysm, cardiac, 65.
of the abdominal aorta, a case of, 343.
of the aorta, 467.
of the arch of the- aorta, 557.
Ani, fissure in, and divulsion of the sphinc-
ter, 179.
pruritus, treatment of, 365.
Anus and rectum, sterile water anesthesia
in operative treatment of diseases of,
510.
Aorta, abdominal, aneurysm of the, 343.

aneurysm of the, 467.
Appet\dages, diseased, 217.
Appendicostomy, 411.
Arhythmias, cardiac, 529.
Argyrol and protargol as substitutes for

nitrate of silver, 29.
Atresia of the bowel, 20.
Atrophy, infantile, etiology and dietetic
treatment of, 506.

Bacteria in scarlatinal and normal throats,

S08.
Bier's hyperemia, 506.
Bile passages and gall-bladder, mortality

after operations upon the, 402.
Bowel, atresia of the, 20.

diagnosis of acute obstruction of, 13.

Bone, frontal, gumma of the, 215,
Bowels, locking of the, 83.
Brain tumors, 84.
Bronchiectasis, 469.

Caesarean section, 26.

Calculi, renal, nephrectomy for hydro-
nephrosis due to, 499.
Cancer of the larynx, 265.
of the skfn, influence of light in produc-
tion of, 32.
of the uterus, radical operation for, 25.
probable hepatic, 560.
Carcinoma, partial gastrectomy for, 170.

primary basal-celled, of the appendix, 544.
Cardiac aneurysm, 65.

arhythmias, 529.
Carpus, tuberculosis of the, 214.
Cell, living, some new conceptions of the, i.
Cells, ethmoid, orbital and meningeal infec-
tion from, 82.
Cerebral tumor, mental symptoms of, 228.
Cerebrospinal fluid, the, in health and dis-
ease, 514.
meningitis, acute pneumococcic, of nasal

origin, 389.
meningitis, treatment of, 260.
Childhood and infancy, the weights of the

viscera in, 505.
Cholecystitis, acute infections, 22.
Chondritis and perichondritis, auricular, 507.
Chorea, a case of Sydenham's, 558.

actue, a case of, 68.
Colic, diagnostic significance of, 173.
renal, 168.

renal, artificial, as a valuable means of
diagnosis, 502.
Congenital coxa vara, 178.
Constipation, "spastic," 83.
Corneal wounds, infection of, by saliva, 264,
Coxa vara, congenital, 178.
Cyst, dermoid, 21.
large ovarian, 127.
ovarian, with twisted pedicle, 66.

ARTICLES.

Cysts, ovarian, situated above the superior
pelvic strait, complicated by pregnancy,
403.

Deformities, and their prevention, 78.
Dementia paralytica, early ocular signs of,

136.

paretic, the clinical aspects of, with special
reference to differential diagnosis, 488.

Dermatoses, the unsuspected parasitic origin
of many, 385.

Dermoid cyst, 21.

Diet in epilepsy, 35.

Digestive and respiratory passages, 133.

Diphtheria, uncertainties of early diagnosis
and necessity of early and vigorous
treatment of, 27.

Dislocation of humerus, congenital, subacro-
mial, excision of the head of the hu-
merus for, 28.

Duodenum, observations upon the anatomy
of the, 403.

Dysmenorrhea, an unusual case of, 121.

Ear disease, chronic suppurative middle,

471-
middle, acute suppuration of, 224.
middle, suppuration, following intranasal

operation, 80.

Editorial :

Absinthism in comparison with alcohol-
ism, 473.

A discovery regarding dead tubercle bacil-
li, 187.

An appeal in behalf of blind artisans, 376.

American Medical Association meeting,
269.

Anesthesia without subjective annoyance,
418.

A new trypanosome peculiar to tropical
Africa, 5x6.

A novel method of reducing infant mor-
tality, 5x7.

A purifier for the lacteal product, 418.

A quick means of preserving milk, 87.

A record of the heat intensity of radium,

138.

A score for radium in surgery, 374.
A word to the wise, 327.

Editorial (Continued) :
Bactericidal action of properly brewed

tea, 517.
Baldness ascribed to improper breathing,

137.
Baron Takaki's observations on beriberi,

417.

Canine disease consequential to coitus, 474.

Decrees affecting nasal deformity, 517.

Discord among doctors, 324.

Disinfecting possibilities of bacteria pecu-
liar to the intestinal tract, 515.

Doctor Reed on race suicide, 233.

Gonorrhea of the female genitalia, 474.

Herdman, William James, Ph. B., M. D.,
LL. D., 564.

Hypnotism: its history, nature, and use,
376, 418, S18, 567.

Investigations bearing on animal intelli-
gence, 272.

Insects as spreaders of infection, 139.

Lead colic resultant from carbonated
water, 517.

Live babes from pregnant subjects of lues,
139.

Malaria ascribed to ankylostoma duoden-
ale, 326.

Medical classics in medical meeting, 180.

Medical investigation of the pestiferous
mosquito, 566.

Medicine in popular magazines, 138.

Obligative anaerobes cultivated in the
presence of oxygen, 566.

Observations in animal optics, 89.

Occult therapy in the Ottoman Empire,

139.
Pedal characteristics of different peoples,

41.
Physicians and philosophers, 42, 90, 234,

273, 327.
Physiologic function of the pituitary body,

41.

Salt-free diet in scarlet fever, 416.

Some peculiarities of the spirochaeta pal-
lida, 417.

Stoicism of earthquake sufferers, 273.

Studies in simian vernacular, 88.

Surgical anesthesia by scopolamin-mor-
phin, 187.

The benignity of dessicated tubercle bacil-
li, 474.

ARTICLES.

Editorial (Continued) :

The catastrophe of the coast, 187.

The demise of Professor Curie in Paris,

233.

The influence of mineral water on mi-
crobes, 272.

The mechanical treatment of mal de mer,

41.

The new clinic in psychiatry at the Uni-
versity of Michigan, 37.

Theories appertaining to appendicitis, 89.

The Portuguese intematfonal congress of
physicians, 231.

The San Francisco earthquake and the
doctors, 373.

The scientific achievements of Schaudinn,

375-

The Toronto meeting of the British Med-
ical Association, 413.

The treatment of cancer with trypsin, 232.

The treatment of sarcoma with mixed
toxins, 40.

The tulase discovery for tuberculosis, 472.

The ubiquity of cell understanding, 326.

Tubercle bacilli in phthisic blood, 474.
Klectricity, static, experience with, 250.
Encephalitis and poliomyelitis in children,

361.

Enuresis, treatment of, 260.
Epilepsy, diet in, 35.
Ethics and etiquette, medical, ^82.
Etiquette and ethics, medical, 482.
Eye, injuries of, following paraffin injections
in the nose, 79.

Faucial tonsils, lymphatic drainage of, 31.
Feeding, influence of, on infant mortality,
221.
in infants, 177.
Fever, hay, palliatives for, 409.
Malta, 75.

scarlet, complications of, 317.
Fissure in ani, and divulsion of the sphinc-
ter, 179.
Fistula, labyrinthine, and paralysis of the
abducens nerve, complicating a case of
middle ear suppuration, 224.
urethral, and prolapsed kidneys, 74.
Fistulas, treatment of certain, 176.
Foot, destruction of tissue and nails of, 215.

Fracture, modern treatment of, 129.
of the ulna during massage following op-
eration for Colles' fracture, 125.
uncommon, 258.
Furunculosis and mastoiditis in external
auditory meatus, 561.

Gall-bladder and bile passages, mortality
after operations upon the, 402.

Gangrene of the tonsil, 134.

Gastrectomy, partial, for carcinoma, 170.

Gastric surgery and chronic ulcer, 313.

Genitalis tractus, pathologic physiology of
the, 145.

Goitre, exophthalmic, 500.

Growths, innocent laryngeal, 364.

Gumma of the frontal bone, 215.

Gunn, Moses, 49.

Headache, persistent, unilateral, due to
nevoid changes in the anterior extrem-
ity of the middle turbinal bone, 509.

Heart disease of nephritis, cause and im-
portance of, 23.

Hemorrhoids, internal, office treatment of,
320.
treatment of, 134.

Hepatic cancer, probable, 560.

Hip disease, the conservative treatment of,
407.

Humerus, excision of the head of, for con-
genital subacromial dislocation, 28.

Hydrocephalus and rachitis treated by radi-
ant energy, 317.

Hydronephrosis due to renal calculi, ne-
phrectomy for, 499.

Hyperemia, Bier's, 506.

Indigestion, fat, in infants, 259.

Infancy and childhood, the weights of the

viscera in, 505,
Infant feeding, rural city milk supplies and

their relation to, 289.
Infantile atrophy, etiology and dietetic treat-
ment of, 506.
paralysis, cerebral and spinal, 361.
pneumonia, cold-air treatment of, 406.

ARTICLES.

Infant mortality, influence of feeding on,

221.

Infants, fat indigestion in, 259.

substitute feeding in, 177.
Infection of corneal wounds by saliva, 264.
Infections, acute pelvic, 123.

cholecystitis, acute, 22.
Insanity, borderland cases of, 62.
Intussusception, 126.

Jaundice, obstructive, Courvoisier's law in
the differential diagnosis of, 218.

Kidneys, prolapsed, and urethral fistula, 74.

Labor, anesthesia in the first stage of, 316.

conduct of, during second stage, 113.
La grippe, remarks on, 118.
Laryngeal growths, the patholog>' of fifty

cases of innocent, 364.
Leprosy or syringomyelia, 74.
Ligaments, round, shortening of the, 315.
Lipoma, polypoid, of the tongue, 508.
Longevity, lessons in, 245, 302, 351, 396.
Lupulin, therapeutics of, 229.
Luxation, congenital, of the head of the

radius, 97.

Mastoid process, necrosis of the, 311.
Mastoidectomy sinus thrombosis, 30.
Mastoiditis and furunculosis in external
auditory meatus, 561.
with Bier's hyperemia, and acute purulent
otitis media, treatment of, 506.
Medical mistakes, 160.
Medical News :
A compilation of centenarians, 571.
A grist of medical graduates, 236.
American Medicine becomes a monthly,

140.
Ann Arbor meeting of nurses' association,

188.
Annual meeting of the Roentgen Ray

Society, 332.
A physician granted patronymic appella-
tion, 44.

Medical News (Continued) :
Arkansas meeting of Valley Association,

422.
Commencement season clinic, 278.
Dedicatory ceremonies at Harvard Col-"

lege, 475.
Life insurance examination fees, 279.
Prepared food products, 331.
The Aesculapian grist at Ann Arbor, 382.
The demise of De Wecker, 44.
The demise of Doctor Doremus, 189.
The national medical election, 278.
The passing of a pioneer Detroit physi-
cian, 475.
The Peninsular gathering of physicians,

278.
The prevention of "putrifaction," 523.
The sudden demise of Schaudinn, 331.
Ziegler, Professor Ernst, 92.
Minor intelligence, 44, 92, 141, 190, 236,
282, 332, 382, 424, 475, 523, 572
Medicolegal questions, 494.
Meniere's disease and Meniere's symptoms,

322.
Meningitis, acute pneumococcic cerebro-
spinal, of nasal origin, 389.
cerebrospinal, treatment of. 260.
Mental diseases, types in, 268.
Meralgia paresthetica, 267.
Metatarsalgia, 400.
Milk supplies, rural city, and their relation

to infant feeding, 289.
Morphin poisoning, 171.
Myasthenia gravis, clinical history and
postmortem examination of five cases
of, 371.
Mycosis occurring in the upper respiratory
tract, 224.

Nasal insufficiency, 409.

obstruction, etiology of, 178.
Necks, broken, observations on, 319.
Necrosis of the mastoid process, 311.
Nephrectomy, 215.
for hydronephrosis due to renal calculi,
499.
Nephritis, heart disease of, cause and im-
portance of, 23.
Neuralgia, trigeminal, the surgical treat-
ment of, 513.
Nodes, cervical lymph, tuberculosis of the,
24-

ARTICLES.

Nose, paraffin injections in the, injuries of
the eye following, 79.
treatment of empyemata of maxillary
..inus through the, 82.
Nostrum evil, 85.

Obituaries :

Allen, Charles Warren, 335.
Cook, Emma, 237.
Curie, Professor, 233.
De Wecker, Baron, 44.
Dor emus, Robert Ogden, 189.
Dunning, Lehman H., 93.
Herdman, William J., 564.
Schaudinn, Fritz, 331.
Skelton, Leonard Lawshe, 141.
Stewart, Morse, 475.
Twecdie, Henry, 526.
Wilson, Jeremiah C, 525.
Wooster, Samuel R., 94.
Ziegler, Professor Ernst, 92.
Obstruction of the bowel, diagnosis of acute,

13.

Opsonins, 536.

Orbit, tumor of, 497.

Osteitis, tuberculous, of the knee, early op-
erative treatment of, 261.

Otitis, chronic purulent, what cases of re-
quire the radical operation, 408.

Otitis media, acute purulent, and mastoid-
itis with Bier's hyperemia, treatment of,

506.

Ovarian cysts situated above the superior
pelvic strait, complicated by pregnancy,
403.

Paralysis, cerebral and spinal infantile, 361.

Paralysis of the abducens nerve, 224.

Parasitic origin of many dermatoses, 385.

Paretic dementia, the clinical aspects of,
with special reference to differential
diagnosis, 488.

Parturition, value of time and natural uter-
ine efforts in, 208.

Pathlogic physiology of the tractus geni-
talis, 145.

Pelvic infections, acute, 123.
strait, ovarian cysts situated above the
superior, complicated by pregnancy, 403.

Perichondritis and chondritis, auricular, 507.

Peritonitis, bacteriology of, in relation to
pelvic surgery, 131.

Physicians, embarking, practical discourse
to, 241.

Physiology, pathologic, of the tractus geni-
talis, 145.

Pneumonia, infantile, cold-air treatment of,
406.
lobar, in infants and children, 133.

Poisoning, morphin, case of, 171.

Poliomyelitis and encephalitis in children,

361.

Polypoid lipoma of the tongue, 508.

Pregnancy complicated by ovarian cysts sit-
uated above the superior pelvic strait,
403.
intraligamentary full-term extrauterine,

404.
spontaneous rupture of the uterus during,
20.

Prostatectomy, mortality after, 259.

Protargol and argyrol as substitutes for
nitrate of silver, 29.

Pruritus ani, treatment of, 365.

Psychasthenia, 136.

Psychoses, organic, cytodiagnosis of, 412.

Pyemia due to middle ear operation, 80.

Pylorus, hypertrophic stenosis of the, 172.

Rachitis and hydrocephalus treated by radi-
ant energy, 316.

Radiant energy, hydrocephalus and rachitis
treated by, 317.

Radius, congenital luxation of the head of,
97.

Reading, how a light should be placed for,
222.

Rectal surgery, anesthesia in, 266.

Rectum and anus, sterile water anesthesia
in operative treatment of diseases of,
510.

Renal calculi, nephrectomy for hydronephro-
sis due to, 499.
colic, 168.

colic, artificial, as a valuable means of
diagnosis, 502.

Respiratory and superior digestive passages,
133.

ARTICLES.

Reviews :

Abdominal operations, 480.

A compound of operative gynecology, 336.

Acute contagious diseases, 143.

A laboratory manual of physiological
chemistry, ig2.

A manual and atlas of dissection, 432.

A treatise on diagnostic methods of ex-
amination, 336.

A treatise on surgery, 480.

A text-book on the practice of gynecol-
ogy, 526.

Coakley's laryngology, 47.

Culbreth's materia medica, 528.

DiflFerential diagnosis and treatment of
disease, 238.

Epitome of the practice of medicine, 19a

Gall-stones and their surgical treatment,
288.

Hare's text-book of practical therapeutics,

48.

International clinics, 47, 144, 479.

Nasal sinus surgery with operations on
nose and throat, 527.

Operative surgery, 143.

Practical pediatrics, 96.

Progressive medicine, 144, 192, 288, 335,
576.

Pulmonary tuberculosis, 575.

Self-poisoning of the individual, 95.

The physical examination of infantS and
young children, 96.

The physician's visiting list for 1907, 576.

The practitioner's visiting list, 144.

The prophylaxis and treatment of inter-
nal diseases, 479.

The ready reference handbook of diseases
of the skin, 95.
Roentgen ray measurement, note on the use
of the milliamper^meter, 512.

Sclerosis, multiple, 321.
Seasickness, a specific for, 323.
Serum therapy, present status of, 36.

therapy, progress in, 514.
Sinusitis, ethmofrontal, three cases of, 320.
Sinus, maxillary, 82.

thrombosis, mastoidectomy, 30.
Skiagraphic technique, 199.
Skin, cancer of the, 32.
Sphincter, divulsion of, and fissure in ani,
179.

Spirochaeta pallida in syphilis, 227.
Stenosis, hypertrophic, of the pylorus, 173
Sterility, the causes of, 360.
Summer School of the University of Mich-
igan, 446.
Surgery, pelvic, bacteriology of peritonitis,

in relation to, 131.
Surgical heresy, 18.

pilgrimage to Arkansas, 200.
Syphilis, a study of, 366.

hereditary, influence of paternal inherit-
ance on, 135.

spirochaeta pallida in, 227.

treatment of, 70.
Syringomyelia or leprosy, 74.

Tendon transplantation in the forearm, 21.
Therapeutics of lupulin, 229.
Therapy, serum, present status of, 36.

serum, progress in, 514.
Thrombosis, mastoidectomy sinus, 30.

sinus and jugular, symptoms and treat-
ment of, 363.
Tonsil, gangrene of, 134.
Tonsillitis and its complications, 164.
Tonsils, faucial, lymphatic drainage of, 31.
Tuberculosis among school children, pre-
vention of, 318.

in children, origin of, ^^.

of the carpus, 214.

of the cervical lymph nodes, 24.

pulmonary, cocillana as an expectorant in,
372.
Tuberculous osteitis of the knee, early op-
erative treatment of, 261.
Tumor, cerebral, mental symptoms of, 228.

of orbit, 497.
Tumors, brain, 84.

of the brain, 563.
Typhoid in children, 504.

Ulcer, chronic, and gastric surgery, 313.

Ulna, fracture of, during massage follow-
ing operation for Colles' fracture, 125.

Urethral fistula and prolapsed kidneys, 74.

Urethra, the various gross pathological con-
ditions of the, as revealed by the
urethroscope, 492.

Urine, retention of, 257.

ARTICLES.

Urticaria, experimental $tudy of some cases

of, 510.
Uterine efforts in parturition, 208.
Uterus, anterior suspension of the, with
complications and secondary operation,
471-
cancer of, radical operation for, 25.
spontaneous rupture of, during pregnancy,
20.

Varicose veins, 215.

veins of the lower limb, 22.
veins, treatment of, 219.

Veins, varicose, 215.

varicose, of the lower limb, 22.

varicose, treatment of, aigi
Vertigo, aural, 564.
Viscera, the weights of the, in infancy and

childhood, 505.
Visual fields as an aid to diagnosis, 337.

Warts, simple, treatment of, by internal

remedies, 267.
Wounds, corneal, infection of, by saliva, 264.

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OCT 23 1907

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A PROFESSIONAL MEDICAL JOURNAL.

VOLUME XXVIII. JANUARY, 1906. NUMBER I.

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ORIGINAL ARTICLES.

MEMOIRS.

SOME NEW CONCEPTIONS OF THE LIVING CELL: ITS

CHEMICAL STRUCTURE AND ITS FUNCTIONS.*

By victor C. VAUGHAN, Ph.D., M. D., LL.D., Ann Arbor. Michigan.

mOFBSSOR or HYGIBKB and PHYSIOLOGXCAL CMBMISTRY, DIRBCTOIt OF THB HYCIBNIC ZJkBOBATOBY, AND
OBAN OP THB PBPABTMBNT OF MBDICINB AND SURGBBY IN THB DNIVBRiMTY OF MICHIGAN.

Mr. Chancellor, Members of the Faculty, and Students: When I
received from my friend, your worthy Dean, an invitation to address
you on this occasion, I delayed my reply for some days, during which
I seriously debated the question with myself. On the one hand, the
memory of previous delightful visits to you and the anticipation of
again being with you urged me to accept ; while the consciousness that
I was not prepared with an address suitable to the occasion, admonished
me that the proper thing to do was to decline. However, when I
recalled the indulgence with which you had received my former efforts,
the decision was reached, and I now have to offer you my best, fully
conscious that it is not good enough, and that you will again have
opportunity to exercise your charity.

Something more than fifteen years have passed since I had the
honor of being the guest of the University of Toronto, and I wish to
say that it is with great pleasure that I have today seen the great
advance that has been made by this noble institution during that time.
I first came here to rejoice with my friend. Professor Ramsay Wright,
on the completion of his biological laboratory, and it is a gratification
now to see that this laboratory has more than fulfilled the promises
made at that time. The research .work of its eminent director, of
Professor McCallum, and others, have carried the name of the Univer-

* Opening address before the Medical Department of the University of Toronto,
October 4, 1905. Reproduced by courtesy of The Canadian Journal of Medicine and
Surgery.

2 ORIGINAL ARTICLES.

sity of Toronto around the world. I have had great pleasure in going
through his new building with Professor Ellis, and in recognizing that
a chemist, whatever may be the fate of prophets, is not without honor
in his own country.

I also rejoice in your splendid new Medical Building, and I envy
the freshman of today, who comes filled with the earnest intention to do
his work well, and who, under these favorable conditions, in the well-
equipped modern laboratories, with such able masters to direct, begins
the study of the beneficent science of medicine. I was greatly rejoiced
on reading in the papers this morning of the munificent gifts that have
been made for the new university hospital. Surely the people of
Toronto are both wise and generous. He who aids in building a hospi-
tal, where human suffering may be relieved, is a practical Christian,
whatever his theological dogma may be. We know not whence we
came, nor can we name the country to which we journey, but we do
know that the burdens placed upon the shoulders of those who travel
along life's highway are not equally distributed, and he who helps his
fellow-man, who is growing faint, serves his God. There is an old
legend concerning the origin of the medical profession, which I may,
I hope, be permitted to repeat. It runs thus : In the olden days when
the world was yet young, a young Hindoo prince, who had all the world
could give, entered a temple and, prostrating himself before the image
of Buddha, besought his god to instruct him in the ways of righteous-
ness. His prayer ended, he felt upon his shoulder a hand as light as
that of a child, and a voice as sweet as that of an angel asked, "Wouldst
thou most acceptably serve thy God? If this be thy desire, go forth
and serve thy fellow-men," and the prince went forth, the first physician
to walk among men.

My visit is not without its tinge of sadness. I miss several faces
that were familiar to this campus fifteen years ago. Of two of these
I must be permitted to say a few words. There was a sweet-mannefed
man, gentle in voice and kind even in reprimand, an eminent ethnolo-
gist, an able historian, whose memory has always been to me a charming
recollection. Such a man was Sir Daniel Wilson. The other was a
professional brother, whose life was a help to those of his own genera-
tion and an inspiration to the young. Such a man was the late Doctor
Graham, of this city and university.

I have decided to briefly discuss "Some New Conceptions of the
Living Cell : Its Chemical Structure and Its Functions." No one can
question the importance of this subject, involving, as it does, biological
problems, which lie at the foundation of all our conceptions and theories
concerning cellular life and cellular activity.

To start ab initio, the cell is made up of matter, and the newer
views on matter must be taken into consideration in formulating a
conception of the cell. When matter becomes endowed with life it does
not cease to be matter ; it does not lose ijs inherent properties ; it is not
released from the laws that govern its structure, its attractions, and its

CONCEPTIONS OF THE LIVING CELL. 3

motions. In studying the organized cell of living thing, whether vege-
table or animal, it should always be borne in mind that it is material in
composition and subject to the fundamental laws that govern matter,
and possessed of those properties essential to matter. In order that
this point, so essential to a proper understanding of the subject, should
be thoroughly appreciated, it may be best to recall some of the prop-
erties of matter as taught by the most advanced science of the day.

Tait says : "Matter is that which can be perceived by the senses, or
is that which can be acted upon by or can exert force." Since force is
the restilt of motion, we may say that anything and everything that
moves or can be moved, or whose position in space may be changed is
matter. There are many forms of matter that cannot be seen or felt,
and can be recognized only by their motions.

Matter is indestructible; it may be successively solid, liquid and
gas, but in undergoing these changes it neither gains nor loses. It has
always been, and it always will be. It is without beginning and will be
without end. Matter consists of infinitely small particles, called atoms.
According to tlje computation of Lord Kelvin, the diameter of an atom
is not greater than a 1-50,000,000 of an inch ; however, all atoms are not
of the same size or weight. When like atoms combine they form
chemical elements, of which about seventy are known. The hydrc^en
atom is the lightest of all known elements, and it therefore is taken
as the base or standard in the determination of atomic weights. When
unlike atoms combine, chemical compounds are formed, and the number
of these is beyond computation. It was supposed, until the discovery
and study of radium, that one chemical element is never converted into
another, and consequently that the number of kinds of atoms is fixed
and unchangeable. However, it has been found that the ;ir-rays of
radium consist of most minute particles, which, when confined in glass,
condense and form another element, helium. With this demonstration
of the formation of one element from another it is within the range
of sanity to suppose that all the elements have been developed from
a primordial ancestor, probably from the universal ether which per-
vades all space.. Nothing has been created; everything has grown.
Even silver, iron, and other metals came into existence by being cast
off from some common ancestral element. The atomic weight of
radium is 225 and that of helium 2.02. It would seem from this that
an atom of the former breaks up into about one hundred atoms of the
latter, and in this way a new element is bom, although in this case it
is probable that the mother atom is split into two or more kinds. It
will be seen from this that even atoms may be split up. Indeed, there
are reasons for believing that the hydrogen atom consists of a nuclear
ion about which some seven hundred particles or electrons revolve, and
an atom of mercury is believed to consist of not less than one hundred
thousand electrons. Atoms and electrons are in constant motion, and
so small are they that the distances between them may be relatively
as great as those between the planets of the solar system. The living

4 ORIGINAL ARTICLES.

cell is c(»iiposed of molecules, made up of atoms, composed of electrons
that are in constant and systematic motion, and may be compared to a
group of stars with attendant suns, each of which is surrounded by its
own planets. A molecule of albumin is of like composition.

Another property of matter is that it is gravitative. Every particle
of matter attracts every other particle. When this attraction is mani-
fest between masses it is called gravitation; between molecules, it is
called cohesion or adhesion, as the molecules held together are alike
or unlike; between atoms it is known as chemical affinity or chemism.

Still another property of matter is inertia, by which term we indi-
cate the inability of matter to change either its rate or direction of
motion without being acted upon by other matter. It is of great
importance that this property of matter be held in mind in the study
of cellular chemistry, and the proper mental picture of a cell molecule
represents each of the atoms in the molecule, and each electron in each
atom moving each about its centre and each at a definite rate. If
such a cell molecule could be cut off permanently from the disturbing
influence of other matter, its atoms and electrons would continue the
same motions, unchanged in direction or rate, throughout eternity,
but, as we shall later see, it would be impossible for living matter to
continue to live apart from other matter. Within the living cell
molecule change in number, kind, and arrangement of atoms is con-
stant ; and the direction ^nd rate of the motion of the atoms are also
susceptible to the influence of other matter and are of constant
occurrence. Whole groups of atoms are physiologically being dropped
from the cellular molecule and being replaced by other groups split
oflF from the pabulum upon which the cell feeds. In this way the
cell renews itself and keeps itself supplied with energy.

Some of the most noted physicists are inclined to the belief that
matter is made up of electric charges, but recognize that this is not a
demonstrated fact as yet, and speak with caution. Lodge says:
"There may possibly be two diflFerent kinds of inertia, which exactly
simulate each other, one electrical and the other material; and those
who hold this as a reasonable possibility are careful to speak of electrons
as 'corpuscles,' meaning charged particles of matter of extremely small
size, much smaller than an atom, consisting of a definite electric charge
and an unknown material nucleus; which nucleus, as they recognize,
but have not yet finally proved, may quite possibly be zero."

The only essential and constant difference between living and
nonliving matter is that within the molecules of the former there is
constant metabolism, while in the latter no such process occurs. We
are to conceive of the living molecule as made up of numerous atoms
and each atom surrounded by its electrons: atoms and electrons in
ceaseless motion, and groups of atoms being constantly cast out of
the molecule and replaced by new groups split off from matter outside
the molecule. As soon as a molecule becomes the seat of assimilation
and excretion, it is no longer dead, it lives. As a result of assimilation

CONCEPTIONS OF THE LIVING CELL. 5

it acquires the property of building up its own tissue ; then polymeriza-
tion follows and reproduction in its simplest form begins. The one
phenomenon always manifested by living matter, and never exhibited
by nonliving matter, is metabolism. Verworm says: "Vital motion,
metabolism, is a complex motion very strongly characterizing the living
organism ; it consists in the continual self-decomposition of living sub-
stance, the giving off to the outside of the decomposition products,
and, in return, the taking in from the outside of certain substances
which give to the organism the material with which to regenerate
itself and grow by the formation of similar groups of atoms, that is,
by polymerization. This is characteristic of all living substance."

I have promised to give you some of the new conceptions of the
living cell, and yet I must admit that Aristotle apparently recognized
that metabolism is the one characteristic of living matter, for he says :
"Life is the assemblage of the operations of nutrition, growth and
destruction." Of course, this Greek philosopher did not know about
cells, molecules, atoms and electrons what is today known, but it must
be acknowledged that he had a clear conception of the most essential
characteristics of living matter. Herbert Spencer has given three
definitions of life, and either may be applied to the conception which
I am trying to present to you. The first is : "Life is the coordination
of actions." The coordination between assimilation and excretion is
certainly essential to life, and failure of this coordination leads to
death. The second is probably the best definition of life ever given,
and fits our conception perfectly. It is: "Life is the definite com-
bination of heterogeneous changes, both simultaneous and successive,
in correspondence with external coexistences and sequences." The
third is practically the same as the second, expressed in simpler terms,
but in my opinion not so satisfactorily. It reads: "Life is the con-
tinuous adjustment of internal relations to external relations." Matter
is alive when it feeds and excretes. Crystals grow and in a sense they
multiply, but their growth is not intramolecular, it is by accretion.
The living molecule not only absorbs, it assimilates. It chemically
alters what it absorbs. The atomic groups taken into the living mole-
cule enter into new combinations. The living molecule is not stable,
but is highly labile. Its composition is never constant and it is never
in a condition of equilibrium. There is a constant reaction between
the living molecule and other molecules. Apart from other matter
it could not exist. There is a constant interchange of atones between
it and other molecules. A condition best designated as latent life
may exist without interchange of atoms between molecules. This is
seen in spores, s^eds and ova. Matter existing in this form may be
awakened into activity by proper stimuli; active life begins with the
interchange of atoms.

Why is there this constant atomic group Interchange between the
living molecule and outside matter? It is for the purpose of supplying
the living molecule with energy. Allen has so ably expressed this

6 ORIGINAL ARTICLES.

fact that I make the following quotation: "The most prominent and
perhaps most fundamental phenomenon of life is what may be described
as the ettergy traffic or 'the function of trading in energy. The chief
physical function of living matter seems to consist in absorbing energy,
storing it in a higher potential state, and afterwards partially expending
it in the kinetic or active form. We find in living matter a peculiar
proneness to change its composition under the stimulus of slight
changes in the energy-equilibrium between itself and its surroundings,
energy being readily absorbed and readily dispersed. The absorption
of energy coincides with deoxidation and the building of large mole-
cules ; conversely the dispersion of energy coincides with oxidation and
the disruption of the large molecules. The building of these large
molecules is always accomplished by slow steps ; but when formed, the
said molecules are very unstable, irritable, or in modern phrase, labile.
They may break down by degrees in some instances; in others their
structure may be so precarious as to collapse on the slightest disturb-
ance."

"The lability of such a molecule may be compared to that of a
house of cards, which can be taken to pieces, card by card, or may
collapse at once. But the word lability is applied, not only to
d^-structive, but also to con-structive instability. The molecules of
living substance are prone to constructive as well as destructive
changes; but, as in the house of cards, the constructive changes are
the most gradual; and as the structure grows more complex, con-
struction becomes more difficult, and collapse is more imminent. It
should be distinctly understood, however, that it is not the mere size
of the molecules that makes them labile, but rather the manner in
which they are linked together, and the amount of potential energy
which is included in the molecule."

It is probable that in the absorption of energy by the living mole-
cule, oxygen is relieved from its combination with carbon or hydrogen
and is attached to nitrogen, while in the liberation of energy the
reverse takes place. Nitrogen and phosphorus, sometimes with iron
and possibly manganese, seem to be, as it were, the master elements
within the living molecule. It is by virtue of their chemism that groups
are torn from extracellular matter, taken into the living molecule and
assimilated by an atomic rearrangement; and furthermore, it is on
account of the lability of the compound thus formed that potential
energy is converted into kinetic and cell work is accomplished.

The question of the origin of life on this world has been ably dis-
cussed by eminent chemists, physicists and biologists. The cosmozoa
theory proposed by Richter holds that cellular life has always existed,
and has been transferred from one planet to another by meteors and
cosmic dust. Richter says: ''Omne vivum ab aeternitate e cellula."
Helmholtz and Lord Kelvin have pronounced this theory not unscien-
tific, and the former makes the following statement : "Meteoric stones
sometimes contain hydrocarbon compounds; the intrinsic light of the

CONCEPTIONS OF THE LIVING CELL. 7

heads of comets shows a spectrum that is very similar to that of the
incandescent electric light in gases containing hydrocarbon. But
carbon is the characteristic element of the organic compounds, of which
living bodies are composed. Who can say whether these bodies that
swarm everywhere through space do not spread also the germs of life
whenever a new world has become capable of affording a dwelling-
place to organic creatures? And this life we mig^t, perhaps, have
reason to regard as even allied to our own in germ, however various
may be the forms in which it might adapt itself to the conditions of its
new dwelling-place."

Preyer objects to the cosmozoa theory that it only sets the question
back to, How did life originate in the universe : and Helmholtz says :
"The true alternative is evident ; organic life has either begun to exist
at some one time, or has existed from eternity."

Pfliiger's theory of the origin of life is the most scientific yet
proposed. He argues that living proteid differs from dead proteid by
the existence in the former of a cyanogen radicle. He says : "In the
formation of cell substance, that is, of living proteid out of food proteid,
a change of the latter takes place, the atoms of nitrogen going into a
cyanogen-like relation with the atoms of carbon, probably with the
absorption of considerable heat." Pfliiger calls attention to the resem-
blances between cyanic acid, HCNO, and living proteid. Both easily
polymerise, the living proteid growing and the cyanic acid forming
the polymeric cynamelid HnOwNnOw. Both yield urea on dissocia-
tion; both are liquid and transparent at low temperature, and both
coagulate at higher temperature. Pfliiger concludes that the beginning
of life depended upon the formation of cyanogen, and then he reminds
us that cyanogen and its compounds are produced only at incandescent
heat. He summarizes as follows: "Accordingly, I would say that
the first proteid to arise was living matter, endowed in all its radicles
with the property of vigorously attracting similar constituents, adding
them chemically to its molecule, and thus growing ad infinitum.
According to this idea, living proteid does not need to have a constant
molecular weight; it is a huge molecule undergoing constant, never-
ending formation and constant decomposition, and probably behaves
towards the living chemical molecules as the sun behaves towards
small meteors."*

It will be seen that according to Pfliiger life is a molecular phe-
nomenon, and it seems to be that this must be true. Nonliving matter,
whether it be inorganic or organic, is relatively stable intramolecularly,
while living matter is never stable within its molecule, which is con-
stantly casting out and as constantly absorbing atomic groups. It
assimilates and it excretes, and these phenomena are its essentials.
Deprive the living molecule of food, and it dies ; prevent its excretion,
and it dies. Reaction between the living molecule and outside matter
is constant, and is necessary to the continuance of life. The fact that

"The different theories of the origin of life are ably discussed by Verworm in his
"General Physiology."

8 ORIGINAL ARTICLES.

life resides in the molecule is, as I have stated, taught in Pfliiger's
theory. It is also recognized by Allen, who, in speaking of living
proteid, says: "It is a molecule of enormous size, and (so far as the
dynamic elements are concerned) its various groups are linked together
by many nitrogen atoms, but not in a chain. It is not a proteid, a
cyan compound, an amid, an amine, nor an alkaloid, but something
that can yield some of them during life and others at its death. Death
consists in the relaxation of the strained relationship of the nitrogen
to the rest of the molecule. When thus 'the silver cord is loosened/
the relaxed groups fall into a state of repose. Most of these groups
are proteids in which the N is peripheral, triad and unoxidized, having
yielded its O to some other element. If, however, such a proteid
molecule be applied to a living cell, it can be linked on again by its N,
which thus once more becomes central."

In his very interesting monograph on the "Biogen Hypothesis,"
Verworm objects to saying that a molecule lives. He states that it is
illogical. "A living thing is only that which demonstrates the phe-
nomenon of life — something that changes itself. A molecule of a
given compound, so long as it remains unchanged, cannot be said to
be living." Then, in order not to speak of living molecules, he intro-
duces the term "biogen molecule," instead of the living molecule.
Surely this is a distinction without a difference. I certainly agree that
a molecule of a germ compound, so long as it remains unchanged,
cannot be said to be living, but the point is that living molecules do not
remain unchanged. When life is latent, as it is in seeds and spores,
the molecules cannot be said to be alive ; but when placed under suitable
conditions, then the change between atomic groups in the molecule
and the external food substance begins, and life first manifests itself.
However, it matters but little, I suppose, whether we speak of living
molecules or biogen molecules.

That life resides within the molecule and that metabolic processes
are intramolecular, are shown by numerous investigations, some of the
most important of which may be briefly stated as follows :

(i) As long ago as 1867 it was shown by Hermann, in his studies
on the metabolism of isolated muscle, that the carbonic acid and lactic
acid that are formed by muscular contraction result from the action
of intramolecular or combined oxygen. This was demonstrated by
the fact that when a muscle was freed from all its uncombined oxygen
under an air pump and then caused to contract in an oxygen-free
medium, it gives off carbonic and lactic acids. Contraction, a vital
muscle phenomenon, is thus shown to result from intramolecular
changes.

(2) In 1875, Pfliiger kept a frog at a temperature of a few degrees
above zero in an atmosphere free from oxygen for twenty-five hours,
and found that during that time the animal continued to give off car-
bonic acid. From this Pfliiger concluded that the living content of the
organism consists of proteid, which he designates "living proteid," in

CONCEPTIONS OF THE LIVING CELL. 9

contradistinction to dead proteid, and that the carbonic acid gas results
from the decomposition of a labile proteid molecule, the nitrogehous
constituents of which are capable, with the help of the fats and car-
bohydrates of the food, to regenerate "the living proteid molecule."

(3) It has been shown by recent research in my own laboratory
that both the toxin and the carbohydrate of the cell of the colon bacillus
are held in chemical combination with other constituents of the cell.
This microorganism will grow in a medium which contains organic
nitrogen, as amino compound only, and with this nitrogen and inor-
ganic salts as its sole food, it builds up by synthetical process a complex
glyco-nucleo-proteid, forming a large molecule which contains as
atomic groups, pentose, nuclein bases, amino and diamino compounds.
These constituents are held chemically in the cell. They cannot be
washed out by physical solvents, and can be isolated only by chemically
breaking down the cell molecule.

Besides the above-mentioned experimental data showing that life
manifests itself by intramolecular reaction, the following general con-
siderations indicate the same thing:

(a) In taking its food the cell, whether it be vegetable or animal,
whether it be that of a unicellular or that of a multicellular organism,
manifests a selective action which can be best explained — indeed, I
might say, can only be explained — on the ground that it is due to
chemical affinity. Mass and molecular attractions are not specific,
while atomic attraction, or chemical affinity, as it is usually designated,
is specific, or at least selective. This fact, as is well known, is the
basis of the side chain theory of Ehrlich, who, upon this principle,
explains the nutrition of cells, the action of many therapeutical agents
and the production and action of antitoxins. It is well known that
certain poisons have a selective action for certain tissues, and this
means that the chemical affinity between the poison and the con-
stituents of certain cells is greater than that between this poison and
other cells. If pharmacology and toxicology ever become exact
sciences it will be, most probably, through investigations directed along
this line.

(b) The fact that the secretions of cells are specific is a strong
argument for the theory that action on the pabulum upon which they
feed is intramolecular. The liver cells produce bile pigments and
acids, each of the digestive fluids elaborates its specific products, the
specific secretions of the adrenals and the thyroid gland have been
studied and are now largely and successfully employed therapeutically.
And still all these organs are supplied with the same blood and lymph.
Certainly the only possible explanation for these well-established facts
is that of a chemical reaction, or an intramolecular reaction, between the
cells and the constituents of the substances with which they are brought
into contact.

While other arguments might be adduced to show that metabolic
processes, the only phenomena with which we are acquainted, that are
characteristic of all living matter and which do not occur in dead mat-

10 ORIGINAL ARTICLES.

ter, are due to intramolecular reactions, it seems to me that those
alr&idy given are sufficient to establish my thesis, that is, life is mole-
cular.

If I have made good my contention so far, it follows that life begins
with the first molecule that is endowed with the capability of growth
and reproduction. The life of such a molecule would depend upon its
continued reaction with matter outside of itself, or, in other words, it
must feed; and reproduction in its simplest form would depend upon
polymerization. In this way the wonderful experiments of Loeb upon
the artificial fertilization of certain ova are easily explained. The ovum
is not alive; it possesses only latent life, and when acted upon by
certain stimuli it begins active life. This stimulus may be a spermata-
zoon or some inorganic salt in a certain definite strength of solution.

If life be molecular, it is possible that its lowest manifestations are
without form. They may be infinitely small, and it is not beyond the
range of possibility that they may exist as solids, liquids, or gases.

Spontaneous generation has never been proved to be impossible;
indeed, it will not be eas^ to disprove spontaneous generation. I agree
with Naegele in the following statement: "One fact — ^that in or-
ganisms inorganic substance becomes organic substance, and that the
organic returns completely to the inorganic — is sufficient to enable
us to deduce by means of the law of causation the spontaneous origin
of organic nature from inorganic. ... If in the physical world all
things stand in causal connection with one another, if all phenomena
proceed along natural paths, then organisms, which build themselves
up from and finally disintegrate into the substances of which inorganic
nature consists, must have originated primitively from inorganic com-
pounds. To deny spontaneous generation is to proclaim a miracle."

The experiments of Tindall, Pasteur, and others, which were sup-
posed to completely and forever overthrow the doctrine of spontaneous
generation, in my humble opinion, did no such thing. They simply
demonstrated that bacteria do not spontaneously generate in meat
infusions and similar media, nothing more. Now, it seems to me that
bacteria, which we frequently call the lowest forms of life, are by no
means certainly entitled to this distinction. They may be the lowest
forms with which we are acquainted, the smallest living things that
we can see with our best microscopes. But chemically they are com-
posed of extremely complex molecules, as has been shown by recent
research in my laboratory. As I have already stated, the cell of the
colon bacillus consists of a highly complex glyco-nucleo-proteid, yield-
ing, on chemical disintegration, a carbohydrate, pentose, the nuclein
bases, the monamino and diamino bodies, as tyrosin, leucin, lysin and
arginin. In other words, chemically the colon molecule is quite as
complex as that of the lower grade tissues in man. Now, if there has
been a chemical, as well as a morphological, evolution, the colon bacillus
is not the lowest form of life; indeed, it must be far removed from the
first molecule that manifested metabolic activity.

CONCEPTIONS OF THE LIVING CELL. 11

The following quotation from Nussbaum, as given by Loeb, shows
that the biologist recognizes that the cell is not the unit of life : "The
cell is not the ultimate physiologic unit, even though it must remain
such for the morpholc^st. We are, however, not able to tell how far
the divisibility of a cell goes, and how we can determine the limit
theoretically. Yet for the present it will be well not to apply to living
matter the conceptions of atoms and molecules, which are well defined
in physical chemistry. The notion, micella, introduced by Naegele,
might also lead to difficulties, as the properties of living matter are
based upon both nuclein and protoplasm. . . . The cell, conse-
quently, represents a multiple of individuals."

Pfliiger has shown that the egg, which has been thought to be a
unit, can give rise to many individuals, and Loeb states that his own
experiments, as well as those of Driesch, confirm this finding.

It is highly probable that the lowest forms of life cannot feed upon
proteids. This is true of the yeast cell. These cells grow rapidly
when placed in a solution of sugar and nitrates, but proteids must be
broken up by putrefactive bacteria before the yeast germs can feed upon
them. Indeed, many of the cells of the body of man cannot feed upon
proteids, which must be split up by the digestive enzymes into much
smaller and simpler groups before the cell molecules can assimilate
them. Even the carbohydrate, starch, must be hydrated before it can
become a source of energy in muscle. Proteid solutions injected into
the blood of man are poisonous, but the same substance, after being
properly split up, is an essential cell food. There are weighty reasons
for believing that proteid is not produced by the lowest forms of life.
However, as proteid, or cellular life, is the only form of life that we
know, it would be quite useless to attempt to go further along this
line.

I have probably said enough concerning spontaneous generation
to bring down upon myself the anathemas of the orthodox in science,
and since my opinion on this subject does not have any essential rela-
tion to the important thesis of this paper, I will leave this point without
further discussion.

If the characteristic phenomena of life are due to intramolecular
reactions, we must conceive the living cell, whether it belong high or
low in the scale of development, as consisting in its essential or vital
part of a chemical compound made up of complex molecules, composed
of atoms, each surrounded by its electrons, all in motion, and with a
constant absorption of atomic groups from other molecules, and whh
a like constant casting off of atomic groups.

This molecule feeds by splitting off such groups as it may need
from the pabulum within its reach, or it may absorb whole molecules,
at the same time rearranging the atoms and making them a part of
itself.

When, in ordinary physiological function, a portion of this molecule,
which we may designate its chemical nucleus, remains undisturbed and

12 ORIGINAL ARTICLES.

regenerates the whole, supplying its waste by the absorption of new
matter.

Cellular assimilation consists in properly locating the recently
acquired groups within the molecule.

Certain cell molecules, under proper stimuli, rearrange their atomic
grouping, polymerise, and thus multiply. This multiplication may be
physiolc^cal or pathological. Rapid proliferation may tend to inability
to function or to react with the food supply, and consequently destroy
the molecule or lead to the death of the cell.

With this conception of a living cell, its secretions consist of the
atomic groups cast out as a result of its reactions with external matter,
and as the cells of different organs are unlike in their chemical com-
position, it follows that the secretions are specific. Outside the body
hemoglobin breaks up, or may be broken up, chemically, into hematin
and globulin. In this case the colored split product contains the iron.
But the liver cells produce from hemoglobin bilirubin and an iron
containing proteid. In this inaction the line of cleavage is quite dif-
ferent from that followed in the ordinary decomposition of hemoglobin.
The secretions of some cells enter into a more or less energetic reaction
with certain extra-cellular compounds with which they come in con-
tact. This is true of the digestive enzymes. Other secretions appar-
ently are made for the purpose of reacting with or at least affecting
the reactions of the molecules of other cells. This seems to be true of
some at least of the so-called internal secretions, such as those of the
thyroid and adrenals.

A most important group of cellular secretions is made up of the
ferments of enzymes. Without going into the history of the theories
that have been advanced concerning the nature of these bodies, it seems
to me that we are no longer justified in speaking of "organized and
unorganized" ferments. All the ferments are cellular products. The
work of Buchner on the ferment of the yeast plant seems to be posi-
tively convincing on this point. Oppenheimer has defined a ferment
in a manner that seems to me to be quite in accord with the latest and
best experimental investigation. His definition is as follows : "A fer-
ment is a catalytically-acting substance which is produced by living
cells, to which it is more or less firmly bound, whilst its action is not
associated with the vital processes of the cells (which produce it) ;
ferments are capable of inaugurating chemical processes which take
place spontaneously (without the presence of the ferments), but pro-
ceed much more slowly. In this process the ferment, itself, remains
unchanged. Ferment action is specific, that is, each ferment manifests
its activity only on substances of certain structural and stereochemical
arrangement."

I am conscious that my translation of this definition is not altogether
satisfactory, and in order to give a more exact interpretation of it,
as I understand it, I offer the following explanatory statements:

( I ) Every ferment is a cellular product ; it is a cellular secretion ;

ACUTE OBSTRUCTION OF THE BOWEL. IS

a substance of definite chemical composition formed by the rearrange-
ment of the atomic groups within the cellular molecule.

(2) The action of the ferment, while it is determined by the cell
which produces it, is not concerned in the "energy traffic" constantly
going on between the molecules of the cell which produced it and other
molecules external to this cell. With our present limited knowledge
of the chemistry of the cell molecule it is impossible, in many cases at
least, to distinguish between the chemical reactions resulting from cell
metabolism and those due to ferments. I am inclined to the opinion
that more exact knowledge will show that the autolytic changes that
take place in many cells after death, and which have furnished the
theme of so many papers recently, will be found not to be due to fer-
ments at all, but to the cessation of metabolic reaction.

(3) The function of a ferment is to hasten chemical reactions which
take place, but much more slowly, without the presence of the ferment.
It seems to me that a clear conception of this point gives one a key to
the action of ferments in general. I have, in the first part of this
paper, called attention to the fact that inertia is a universal property of
matter; that the direction and rate of movement in matter can not
be altered spontaneously. A ferment is a substance which by its
presence changes the tempo of chemical reaction. I am fully aware
that this does not explain why the ferment acts by its presence, but
it is worth much to have a conception of hozv it acts, provided, of course,
that this conception be correct. Furthermore, it must be admitted that
the modus operandi of ferments is still beyond our ken. Some think
that certain atoms or atomic groups are detached from one of the sub-
stances, combine with the ferment, and then are passed on to the other
substance. On this supposition the ferment does enter into the reac-
tion, but is constantly regenerated. Others hold that the ferment
combines with the fermentable substance, making its molecule so labile
that it falls to pieces, and that in the dissociation the ferment is again
set free. There are weighty objections to either of these theories, but
time will not permit me to state them in this paper, which is intended
to be suggestive rather than exhaustive.

ON THE DIAGNOSIS OF ACUTE OBSTRUCTION OF
THE BOWEL.*

By THEODORE A. McGRAW. A. B., M. D., LL. D.. Detroit, Michigan.

I OP SVBGBRY AND CLINICAL SURGBRT IN THB OBTROIT COLLBGB OF MBDICINB.

Disorders, which increase rapidly in virulence and if unrelieved

cause speedy death, demand early and correct diagnosis and positive

treatment. Of such, there are none which are more urgent than acute

intestinal obstructions, and none in which hesitation and delay are more

disastrous. The physician who ponders too long in these cases over

the diagnosis, comes to a decision too late for his patient's salvation.

*Read at the Add Arbor meetitifB^ of the First Concilor District Medical
Society, December, 22, 1905.

14 ORIGINAL ARTICLES.

Schlange divides intestinal obstructions into two classes, the dynamic
and the mechanical. The dynamic are paralytic conditions which are
usually secondary to other troubles. They may be caused by nervous
shock. I met with this form once in a case of acute pancreatitis, which
I operated on in Monroe with Doctor Southworth. A man of forty-
five years was seized with a violent pain in the epigastrium and fell at
once into a collapse. I saw him twenty-four hours later. He had then
rallied s(»newhat but was suffering great pain in the abdomen. There
was great distension and the abdomen was very sore. I diagnosticated
the trouble as perforation by a gastric ulcer and expected to find the
intestines highly inflamed. On opening the abdomen, however, I
found them of normal color and appearance but highly distended with
gas. On lifting up the stomach an abscess was discovered in the tail
of the pancreas.

These cases are uncommon. The usual cause of dynamic obstruc-
tion is inflammation of the peritoneum of which the type is a sup-
purative appendicitis. The treatment of these cases is that proper for
the inflammation which causes them. Their symptoms, pathology and
treatment have been the subject of innumerable treatises and discus-
sions and are familiar to all intelligent practitioners. I shall not, there-
fore, discuss them in this paper but confine my remarks to obstructions
caused by mechanical forces. These include all cases of hernia, vol-
vulus and intussusception, and of obstructions caused by inflammatory
bands, by adherent diverticulums, by tumors and cancers, by faults in
development and by fecal impactions and foreign bodies.

Mechanical obstructions may be divided into two classes: those
which suddenly and completely occlude a gut and those which cause
only a partial stenosis of slow development. This is a highly practical
division, inasmuch as the two classes differ much in symptoms and
demand different treatment.

It is the obstructions due to the various forms of strangulation and
to intussusception which are most speedily fatal and which, never-
theless, if operated on early, offer the best results. In many cases
an operation in the first twelve hours after the seizure would have little
more danger than an exploratory incision, while operations after the
lapse of forty-eight hours are almost always followed by death. The
symptoms caused by all these various forms of acute mechanical
obstruction are uniformly the same, modified only by the seat of the
obstruction, as it occurs in the large or small intestine, and by the
idiosyncracies of the patient. There is first a sudden and violent pain
in the abdomen, followed by nervous shock and vomiting. There is
in the first twelve hours, as a rule, but little abdominal tenderness and
the patient rarely objects to the manipulation of the abdomen by the
surgeon. Almost immediately, however, there begins a perceptible
distension of the abdomen which, in the very beginning, is localized
and confined to the affected coil but soon involves the intestines above
it. In persons with thin abdominal walls, the coil which is the seat

ACUTE OBSTRUCTION OF THE BOWEL. 15

of the injury may be discovered as a projecting spot on the abdomen.
It is distended and paralyzed and will not contract under any stimulus.
Vomiting does not relieve the nausea, and continues without cessation.
The bowels are obsttnately constipated and do not respond to pur-
gatives but may discharge such of their contents as are contained in
the part below the constriction. When, as sometimes happens, the
affected coil is in the pelvis, there may be no distension of the abdomen
but the swollen intestine may be felt by rectal or vaginal examination.
This was the case in a boy upon whom I operated on the seventh of this
month. He had been ill over three days when he was brought to the
hospital enormously distended. His physician told me that the abdo-
men during the first two days was flat and unsensative. I found a
black and gangrenous volvulus of large size, which I fished out of the
pelvis. In these cases a careful examination of the pelvic cavity
through the vagina or rectum should never be omitted.

The course of the distension in obstruction has an important bearing
on the diagnosis. The abdomen is not suddenly inflated as in severe
acute enteritis or peritonitis ; aflFecting at first only one coil, the swelling
is for some hours localized and moderate, and only gradually extends
to the gut which lies above the constriction. In the last stages, how-
ever, the whole abdomen may become swollen to its utmost capacity.
In fat people it is much more difficult to map out the affected coils.

It is characteristic of obstruction in the early stages that the result-
ing swelling is comparatively free from soreness. I have, indeed, seen
several patients in whom this freedom from tenderness on pressure
continued into the second and third day, even though they were suffer- *
ing extreme pain. In fact, I have come to look upon the disproportion
between the pain of obstruction and the soreness of the abdomen as
pathognomonic of the disorder. A patient will from the very begin-
ning complain bitterly of pain but will, without flinching, allow the
surgeon to thoroughly manipulate and examine the abdomen. There
may be some tenderness in spots but it is comparatively slight and
unimportant. There are very few morbid conditions in which this
contrast between agonizing abdominal pain and nearly complete free-
dom from abdominal soreness are found in the same degree. Cor-
responding with this freedom from soreness, the abdominal walls, in
most cases, are relaxed and devoid of tension until, at the end of thirty-
six or forty-eight hours, all symptoms become aggravated by septic
absorption. The increase of indican in the urine is of no avail for
early diagnosis, as it does not become apparent before the lapse of
twenty-four hours. In obstruction the temperature remains nearly
normal until the conditions become septic, when it will rise rapidly
and continuously until death. It is on the combination of symptcwns
and on the order of the sequence that the physician must base his
diagnosis. There is not a S3rmptom of obstruction which may not be
present in other maladies but there are few diseases in which they will
occur in the same order and in the same connection.

le ORIGINAL ARTICLES.

If we pass in review the other troubles which may perplex the prac-
titioner in his diagnosis we may gain a clearer picture of that first stage
in which alone operations can be done with nearly certain success.

Obstruction may, first of all, be mistaken for indigestion with
autointoxication. The severer forms of this kind of trouble are
sometimes ushered in by severe abdominal pain, vomiting and collapse,
followed by some tenderness and distension. It is rarely, however,
that the nervous shock is as severe as in obstruction. The pain is
more colicky in character, the bloating, when it occurs, is less localized
and of more rapid development, and there is more fever. The one
deciding symptom is the occurrence of diarrhea, which is the usual
result of the condition. Should the bowels not move spontaneously,
purgatives or enemas will almost invariably produce the desired effect.
This is the rule, too, with all forms of enteritis. Osier, indeed, men-
tions a case which was mistaken for obstruction but does not say any-
thing as to the condition of the bowels. The coexistence of constipa-
tion with severe enteritis is so rare that it may be left out of our
calculations in forming our opinion.

Bilious colic produced by the passage of gall-stones may cause
great agony, feeble pulse, vomiting and temporary collapse. It is»
however, usually of short duration and causes neither bloating nor con-
stipation. If the trouble is prolonged, there will be tenderness in
the region of the gall-ducts, and if the common duct is the seat of the
disorder, there will be jaundice. It rarely causes the permanent pros-
tration of obstruction, unless associated with severe suppurative
cholecystitis, in which case there will be chills and high fever as well
as great local soreness.

The colic of lead poisoning could hardly be mistaken for intestinal
obstruction, notwithstanding the occurrence of constipation. The his-
tory of the patient, his occupation, his continued ill health, the blue
line of the gums are all distinguishing features. The symptoms are
relieved by opium and the constipation is apt to alternate with diarrhea.
The patient has a history of multiple attacks, which gradually increase
in severity. There is not much distension and, if any exists, it will
disappear under opiates, in this respect differing sharply from the dis-
tension of obstruction.

In renal colic the patient often suffers severe shock and great pain.
There is sometimes, but not always, nausea and vomiting. The pain
aflfects the back, the kidneys, the ureters and the bladder. Micturition
is often painful and the urine contains albumin and blood. There is
tenderness along the course of the affected ureter. The bowels may
or may not be constipated, but are rarely bloated.

Acute pancreatitis, more than any other malady, may simulate intes-
tinal obstruction. Beginning with an agonizing pain in the abdomen,
with great shock and vomiting, there is a rapid distension of the
abdomen and a tendency to collapse. The very rapidity with which
the symptoms develop distinguishes the disorder from obstruction, in

ACUTE OBSTRUCTION OF THE BOWEL. 17

which the growth of the abdominal distension is much more slow.
•The pain in pancreatitis and the tenderness are felt across the abdo-
men in the region of the pancreas. The fever of pancreatitis begins
much earlier than that of intestinal stoppage. As regards those inflam-
matory affections which cause bloating and intestinal paralysis, they are
all distinguished by high fever, leucocytosis and abd<nninal tension and
need no further discussion in this place. In the diagnosis of invagina-
tion, the finger may often detect the invaginated gut in the rectum in
the shape of the end of a tube projecting into the bowel. This feeling,
however, may be very deceptive, as I found in a case of Doctor Qiapo-
ton's upon which I operated. The child had a severe attack of obstruc-
tion and I felt as high up as I could reach a protrusion of this form.
On abdominal section, however, I found no invagination but a volvulus
high up. The pelvis was full of distended coils of intestines, whose
pressure upon the rectal wall had forced it in and caused the deceptive
protusion.

In discussing the symptoms of acute obstruction we must not forget
those forms caused by the obturation of the gut by intestinal contents.
I was once called into the country to operate on a woman who had the
evening before eaten an enormous quantity of pop corn, which she did
not even take the trouble to chew. I found her suffering from agon-
izing pain which had continued for the twenty-four hours. Her
abdomen was enormously distended. I was preparing to operate,
when she had a sudden evacuation of a g^eat mass of undigested pop
com, and relief from all her symptoms. It is, of course, important to
distinguish these cases from those in which the stoppage is due to
strangulation or intussusception.

I have not spoken of the later symptoms of obstruction, such a fecal
vomiting, high fever, and failing pulse, because the diagnosis should
never wait upon their appearance. I am confident that in nineteen
cases out of twenty the physician could diagnosticate acute obstruction,
if he would become thoroughly conversant with the typical symptoms.

If a patient is seized with an agonizing pain in the abdomen, fol-
lowed by shock, nausea, vomiting and collapse, — if then there occurs a
localized swelling of the abdomen or pelvic cavity, if in that swelling
no stimulus can cause vernricular motion, if during the twenty-four
hours there is very little abdominal tenderness and no abdominal ten-
sion, if the bowels are obstinately constipated, if the abdominal swelling
slowly increases until the afferent coils all become distended, if with all
of the disturbance there is little or no rise in temperature, there can be
no doubt as to the nature of the trouble, for there is no other malady
which will offer the same complex of symptoms in the same sequence.

Those cases only are doubtful in which some of these symptoms are
lacking or are modified by the existence of other morbid conditions.
Thus the localization of the primary swelling may be rendered impos-
sible by a fat abdomen. There may be some chronic inflammatory con-
dition caiising abdominal tenderness, tension and swelling. There may

18 ORIGINAL ARTICLES.

be one or two evacuations of feces which have been lodged below the
point of obstruction, and there may be histories of previous attacks of
abdominal pain which may prejudice the diagnosis, but even with all
the possibilities of mistake, a careful watch and intelligent analysis of
the phenomena will usually lead to a correct conclusion.

Even when the diagnosis of obstruction has been made, the occur-
rence of a fecal evacuation and the subsidence of some of the more dis-
tressing symptoms may lead to a mistaken belief that there has been a
correction of the morbid condition. The patient may feel relief from
pain, but the distension increases, the pulse beats faster and feebler and
the temperature rises. It may be laid down as a positive rule that
relief from obstruction is always followed quickly by a relief from
distension.

This is an index to which the physician should look for guidance
when there is an apparent improvement, and never delay operative
measures when the distensk>n is persistent. We may hope to cure
cases of complete acute obstruction only when we meet the emergency
by operation within the first twenty-four hours, and it behooves every
practitioner of medicine to study carefully the means of diagnosis and
to be prompt in his action.

TRANSACTIONS.

CLINICAL SOCIETY OF THE NEW YORK POLYCLINIC.

STATED MEETING, DECEMBER 4, 1905.
The President, JOHN J. MacPHEE, M. D., in the Chair.
Reported by FREDERICK C. KELLER, M. D., Secretary.

READING OF PAPERS.
SURGICAL HERESY.

Doctor John A. Bodine read a paper bearing the above title. He
said in part :

The first slipping away from the faith of our forefathers was in
"Where and How to Amputate." No article in textual creed is
stronger than, "Save all you can in amputations." The various and
multiform amputations through the complex tarsus and metatarsus
bones were the result of the necessity for speed before the advent of
anesthesia. This golden rule was also strengthened by the argument
that in amputations the nearer the trunk the greater the death rate, Ad
still further bedrocked in the belief of the patient that the less of his
anatomy lost, the less xA a cripple he was. The advent of skilled pros-
thetic surgery has done away with peg-legs and crutches for the unfor-
tunate victims of amputations, and today instead of traditional anatomic
and sentimental arguments, one should be guided by a new article of

CLINICAL SOCIETY. 1» .

faith : "Amputate where the limbmaker can best supply the loss." Save
all you can from tip of toe to the tarso-metatarsal joint, and discard
every one of the many technical amputations through the tarsus in
favor of the Syms' amputation at the ankle-joint. There is weighty
prosthetic evidence that even this point of amputation should be dis-
carded in favor of removal seven inches above the ground line. There
is but one American firm of limbmakers which claims it can fit partial
foot amputations with a satisfactory appliance, and even it admits that
the advantage is chiefly economic, the apparatus costing less than in
the case of higher amputations.

After leaving the point of seven inches above the ground line, the
rule of save every inch possible holds good until within two inches of
the knee-joint. In amputations of the thigh above this point, one
should save every inch possible.

In the event of future improvements in artificial substitutes, nulli-
fying the potency of the speaker's. argument, he submitted that in par-
tial foot amputations the technical and ccxnplicated textual amputations
should be ^discarded and the foot treated as one bone, the rule then
being, "Save all you can, from toe to hip-joint."

There is a tendency today Jo attach too much importance to the
laboratory verdict in diagnosis of surgical lesions. Important as this
evidence is, it is not always pathognomonic, and in few surgical diseases,
alone and unaided, can it be relied upon to formulate a diagnosis. It
furnished evidence, valuable evidence, but unless clihical history and
clinical symptoms support this testimony the laboratory evidence should
be discarded. In the surgical lesions of the stomach, can cancer,
pyloric obstruction or ulcer be diagnosticated alone by the test-tube or
microscope? Can chemical or microscopic examination of the feces
locate or even diagnosticate surgical lesions of the intestinal tract?
Which should one refuse elective operation, a patient who passed a
low quantity of urine, with low specific gravity, or one with full quan-
tity of normal specific gravity, with all the pathologic casts and epithe-
lium discoverable with the microscope ?

DISCUSSION.

Doctor Ferdinand M. Jeffries: So far as Doctor Bodine's
remarks concern the laboratory, I must agree with him in the main,
but some of his assertions I cannot coincide with. With regard to
cancer, I feel that if the pathologist's report is that of cancer, no
matter what the clinical findings may be the surgeon should proceed
on the assumption that it is malignant in character. Regarding appen-
dicitis, it is generally known that hematology is not the useful diag-
nostic aid that at one time it was hoped it would be, nevertheless,
instances are on record in which it has been of great service. There-
fore, the patient should be given the benefit of this examination on all
occasions. The surgeon should give the benefit of all clinical aids ; the
laboratory is one of them.

20 ORIGINAL ARTICLES.

REPORTS OF CASES.
ATRESIA OF THE BOWEL,

Doctor Joseph E. Fuld: I wish to show this specimen. The
child was bom normally, at full term, and on the morning of the third
day vomited material which looked like meconium. It had not defe-
cated since birth, and refused the breast. ^Physical examination showed
a well-formed, healthy baby, with no outward deformities. The abdo-
men presented marked lateral and median distension, but no signs of
hernia. Examination with a large sized Kelly cystoscope showed a
distinct narrowing of the lumen of the bowel between one and one-
half and one and three-quarters inches from the anus. In the centre of
the narrowest part a small dimple was distinctly visible, and through
this a uterine sound was introduced with some difficulty for about one
and one-quarter inches. No mass could be felt in the pelvis. A diag-
nosis of atresia recti was made, and iliostomy was performed under
chloroform anesthesia. A median incision two inches long was made
below the umbilicus, and in trying to get into the peritoneal cavity the
much-distended bladder, which resembled the parietal peritoneum, was
nicked and considerable urine escaped. An artificial anus was made
in the lowest part of the ileum, which was packed off and surrounded
with gauze. The patient left the table in a fair condition, but was not
rielieved by the operation, and died thirteen hours later. Postmortem
examination showed the small intestine to be full of meconium and
considerably distended. The pylorus was distinctly thickened for a
distance of about three-quarters of an inch, making a firm ring, and
producing a slight stenosis. Section through the thickened tissue
showed very marked increase of the muscular layer. At the normal
end of the ileum, instead of the normal valve there was complete
closure. Beyond this the large bowel was patent throughout, com-
municating below with the rectum. In the centre of the septum was a
dimple, corresponding to the ileocecal valve. The large bowel wa:>
the size of an adult ureter, and the cecum was about three-quarters of
an inch in length and about twice the size of the sigmoid colon.

SPONTANEOUS RUPTURE OF THE UTERUS DURING PREGNANCY,

Doctor Louis J. Ladinski : I desire to show a uterus and adnexa
which I removed from a patient about a week ago. The history given
was that pregnancy followed four years after operation at the Polyclinic
Hospital, and just prior to impregnation there was chronic endome-
tritis with mattery discharge. Examination through the vagina during
the fourth month of pregnancy showed the uterus to be adherent, but
there was no deformity in size, form or position. Three days before
operation a small blood spot was noticed, and I adyised absolute rest
in bed and morphin. There was no further showing of blood, but the
following day the patient complained of pain in her back, and two days
later she collapsed. Her pulse was rapid and almost imperceptible at
times, and she had intense pallor and rapid respiration. Her abdomen

CLINICAL SOCIETY. 21;

was distended, not in the shape of a dome, but over its entire surface.
A diagnosis of ruptured abdominal pregnancy was made, and immedi-
ate operation advised. When the patient was placed on the operating
table the fetus was found in its sac, floating about in the abdomen.
There was a large rent in the uterus. The patient made a good
recovery. Uterine rupture during pregnancy is rare, and must not be
confounded with rupture during labor. The most frequent cause for
the former is the giving way of the scar of a previous Cesarean section,
or of the connective tissue formed after a deep curettage. In the case
described, one portion of the posterior wall of the uterus was as thin as
paper. If a history of the operation performed four years before could
be obtained it would assist in determining the cause of this condition.

DISCUSSION.

Doctor Benjamin Torrens : Possibly the patient was the same as
one on whom I operated about four years ago at the Polyclinic Hos-
pital. On inserting the curet into the uterine cavity, it was found that
the instrument entered the abdominal cavity through an opening in the
anterior uterine wall. It was immediatly withdrawn, and digital
examination disclosed two perforations of the wall, with about one inch
of connective tissue separating them. Each of the openings was large
enough to admit the passage of two fingers. The uterus was packed
with iodoform gauze, the culdesac of Douglas was opened, and the
small intestine was found adherent to the anterior uterine wall at the
site of perforation. This was detached and the pelvis packed with
gauze. The patient made an uneventful recovery.

Doctor Robert H. M. Dawbarn: This case reminds me of an
instance in which I made a diagnosis of abdominal rupture of preg-
nancy, even going so far as to determine the position of the fetus.
There was some bleeding from the uterus, which was enlarged and
quite soft. The abdomen, when opened, allowed the escape of a very
great amount of bloody material, and this being removed, it was seen
that all of the viscera, the bowels especially, were covered with a new
growth which proved to be sarcoma, the largest clump of which had
been mistaken for the fetus.

DERMOID CYST.

Doctor Dawbarn : I also wish to show a dermoid cyst which I
removed a week ago from a girl nine years of age. The dermoid is
much larger than the average specimen of its kind. There is a Kstory
of half a dozen paroxysms of pain, and when the specimen was removed
the pedicle was found to be twisted upon itself a great many times.
Apparently this occurred coincidentally with the pain, and of course
occasioned hemorrhage of the sac. The solid portion of the cyst is
about the size of a small tgg and is filled with teeth and bones.

TENDON TRANSPLANTATION IN THE FOREARM,

Doctor John A. Bodine : I wish to present this patient. He is a
butcher by trade, and was on the top of a high stepladder when he
slipped and caught at a large meat hook on the side of the wall. The

22 ORIGINAL ARTICLES.

hook penetrated the forearm at the base of the thum, picking up the
three tendons on the radial side — the two tendons forming the anatom-
ical snuff-box and that of the supinator longus. He swung from this
hook with his entire weight of one hundred seventy pounds. The
tendons did not break, but pulled loose from their attachments to the
muscles in the forearm, one of them hanging down for twelve inches.
He wrapped his butcher apron around the forearm and tendons and in
a few hours was on the operating table. The tendons were identified
and two of them passed through the canal in the anterior ligament of
the wrist and sutured in their proper positions. The loose tendon of
the supinator longus, however, was so long that opening of the muscu-
lar planes of the forearm, near the elbow, would have been necessary in
order to stitch it in place. It was therefore thought best to transplant
it into the tendons of the extensor primi internodii pollicis. The wound
healed kindly and the patient can now do with this thumb all that he
can do with the other one.

VARICOSE VEINS OF THE LOWER L2MB,

Doctor Bodine: I also wish to present this patient. Of middle
life, she presented for operation the worst type of this condition. Great
masses of infected thrombi were present on the inner side of the leg.
Three weeks' rest in bed, with ice-bags, et cetera, was insisted upon,
until all inflammation and sepsis had disappeared. She was then oper-
ated upon. It is my belief that when the Trendelenberg operation can-
not be utilized the only other to be recommended is that of excision of
the entire internal saphenous vein, because if the blood current in the
vein is cut off by any other operation, the walls of the useless vein may
become a foreign body and require removal. The operation recom-
mended by me is that of Caseta, in which the entire vein is removed
through three or four small cuts in the overlying skin, the vein being
pulled out subcutaneously, the numerous tributary vessels being torn
across, but not litigated. At the junction of the middle with the lower
third of the leg, the skin and subcutaneous fascia are then cut through
to the muscles, the cut encircling the entire limb. After this operation
the patient is usually in the hospital for two weeks. In every one of
the twenty cases in which the speaker had operated according to this
method the cure had been perfect.

ACUTE INFECTIOUS CHOLECYSTITIS.
Doctor Bodine: Here is a girl, seven years of age, who entered
the hospital fot^r weeks ago. The question of diagnosis is interesting
in -this case, because, judging from the symptoms, the condition might
have been intestinal obstruction, pneumonia, diaphragmatic abscess,
appendicitis, or acute infectious cholecystitis. As is well known, at
times it is very difficult to differentiate in these acute abdominal lesions.
Her vomiting was not progressive and her fever was too high for
intestinal obstruction. The principal point of tenderness was too high
> for appendicitis, unless it were of the type in which the pain is reflected
to the liver. Her entire right abdomen was rigid, and respiration.

HEART DISEASE OF NEPHRITIS 28

while rapid, was not the dominant feature of the situation, although a
cough was present from bronchitis. Diagnosis of acute infection of
the gall-bladder was therefore tentatively made, and proved correct on
operation. The liver was two and one-half inches below the costal
border, and projecting below the liver was the tense, swollen gall-
bladder. This was quickly stitched to the abdominal wall, drained,
but not removed. The child's condition was so critical that speed was
an essential feature of the case. Four months previous to this illness
she had an unusually severe attack of measles, followed by a persistent
bronchitis and cough. From .that time to the present illness she has
complained frequently of pain in the pit of her stomach, so it seems
quite probable that the measles were the cause of the infected gall-blad-
der by metastasis.

ORIGINAL ABSTRACTS.

MEDICINE.

By GEORGE DOCK, A.M., M. D., D.Sc, Ann Arbor, Michigan.

PltOFUSOR OF MBDICINS IN TMB UMIVBRSITY OP BflCMIGAlt.

AND

DAVID MURRAY COWIE, M. D., Ann Arbor, Michigan.

FIRST ASSISTANT IN BfBDIClNB IN THB UNIVBBSITV OF BflCMIGAN.

THE CAUSE AND IMPORTANCE OF THE HEART DIS-
EASE OF NEPHRITIS.

Passler (Sammlung Klin. Vortrdge, Inn. Med. Number CXXIII)
has made a study of this subject, so often discussed in the past, and has
brought to it the most advanced knowledge of cardiac physiology and
pathology, since he has been an active coworker with Krehl, Romberg
and others of the Leipzig school. Only the most important conclusions
can be given here.

( 1 ) The cardiac hypertrophy in nephritis is the result of the kidney
disease.

(2) There is probably at first an increased irritability of the vaso-
'constrictor apparatus in consequence of the renal lesion, subsequently

arterial spasm and increased resistance of the greater circulation. In
cases where there is extensive arteriosclerosis, especially in the thoracic
aorta or the small arteries of numerous organs in the splanchnic area,
part of the hypertrophy of the left ventricle must be attributed to this
complication.

(3) The hypertrophy of the left auricle and the right heart in
nephritis is a result of insufficiency of the left ventricle.

(4) The polyuria of many renal diseases, especially of contracted
kidney, does not depend upon an increased "filter pressure" of the
glomerular capillaries ; it is much more probable that the blood pressure

24 ORIGINAL ABSTRACTS.

in the renal capillaries is not elevated above normal even in cases of the
highest arterial pressure, as the excess must be used in overcoming the
resistance in the small arteries.

(S) Therapeutic measures for preservation of compensation, and
in disturbed compensation of the heart in interstitial nephritis, must
regard not only the increase of cardiac power, but more especially the
lowering of arterial r^istance. (For the latter purpose the author
recommends nitr(^lyccrin). G. d.

SURGERY.

By frank BANGHART WALKER, Ph. B., M, D., Detroit. Michigan.

rROVBSSOK or SUKGBKT AMD OPBRATiyB SUKGBKT IN THB DBTKOIT POSTGKADUATB SCHOOL OV MBDICIM
ADJUMCT PKOFBStOR OF OPBKATIVB SUBGBKT IN THB DBTBOIT COLLACB OF MBDICINB.

AND

CYRENUS GARRITT DARLING, M. D., Ann Arbor. Michigan.

CLINICAL ntOFBSSOB OF SUBGBKT IN THB VNIVBBSITT OF MICHIGAN.

TUBERCULOSIS OF THE CERVICAL LYMPH NODES.

Daniel Eisendrath, M. D., of Chicago, in Surgery, Gynecology
and Obstetrics, Volume II, Number I.

This old, familiar subject has made some advances of late, so that
the cause, diagnosis and treatment at the present time will be consid-
ered. It has long been known that the tonsils are the common portals
of entry of infection in the cervical lymph nodes. This has been con-
firmed beyond doubt by examination of the tonsils and adenoids
removed from children. When the children crawl on the floor their
tonsils probably become infected by the dust which lodges in them.

Infection may also come from the temporal bone or through
carious teeth, by tubucular lesions of the buccal and mucous membranes.
These latter represent a very small proportion of the cases. The tuber-
cular organisms may remain latent in the cervical lymph nodes for many
years, and then suddenly become active. Every case should be care-
fully examined before operation to see if it is complicated by disease
of the tonsils, or by the presence of adenoids. The diagnosis of the
chronic forms, such as have extended over .a period of months or years,
will be easy, and other cases, also, where the disease runs a very acute
course so that caseation may occur, within two or three weeks after the
onset of the disease.

Another class should be considered which Fischer has termed a
pseudoleukemic form of tubercular lymph nodes, where the axillary
and inguinal node are enlarged as well as the cervical. There is a grad-
ual enlargement; with no tendency to softening, or the formation of
adhesions between adjacent nodes.

Without a reliable history it is impossible to make a diagnosis.
Besides these may be mentioned syphilitic lymphatic leukemia, chronic
nontubercular hyperplastic nodes, lymposarcoma, and secondary car-

CANCER OF THE UTERUS. 25

cinomata. The treatment is divided into prophylactic, nonoperativc,
and operative. Prophylaxis is the same as may be applied in all
instances for avoiding tuberculosis. To this may be added the removal
of diseased tonsils and adenoids whenever found.

When, for any reason, an operation is deemed inadvisable or objected
to, the patient should be sent to the mountains or seashore. When this
is impossible tonics of cod-liver oil, guaiacol, or iodide of iron will be
beneficial. If the condition is active medical treatment is of little avail.

The operative treatment consists in removing every tuberculous
node, and, at the same time, the tonsil and diseased adenoids. The
incision is made over the middle of the sterno-cleido-mastoid from one
end to the other if necessary, and all the sinuses if they exist, are dis-
sected out. The muscle is pulled backwards and the nodes exposed.
Care is taken to catch every bleeding point at once. Few of the vessels
require ligature except the external jugular vein, which is nearly always
severed. The dissection is made with blunt-pointed, short-bladed,
curved scissors. The writer states that in this way he has exposed the
internal jugular vein from the chin to the clavicle without injury. By
this method nodes can easily be stripped from the wall of the vein with-
out injury. Occasionally a short vessel Avill be found extending directly
from the internal jugular vein to the overlying node which will give
troublesome bleeding if it is cut. This may be seized with a stitch and
a parietal ligature applied. Care must be taken not to injure the spinal
accessory nerve which emerges from the sterno-mastoid about the
middle, and passes almost transversely across the triangle to enter the
trapezius. A number of enlarged nodes are sometimes encountered at
this point. The thoracic duct must not be forgotten when operating
on the left side. A thorough removal of all fat will greatly aid in
securing a perfect cure. c. g. d.

GYNECOLOGY,

By REUBEN PETERSON, A. B., M. D., Ann Arbor, Michigan.
ntoratsox or gthbcologt and obstbtxics in tmb ukivbesitt op Michigan.

AND
CHRISTOPHER GREGG PARNALL, A. B., M. D.. Ann Arbor. Michigan.

FIRST ASSISTANT IN GTNBCOX.OGT AND OMTBTUCS IN TMB UNIVBXSITY OV MICHIGAN.

HAS EXPERIENCE SUSTAINED THE MORE RADICAL
OPERATION FOR CANCER OF THE UTERUS?

Clark (Surgery, Gynecology, and Obstetrics, Volume II, Number
II) reviews his experience in the operative treatment of cancer of the
uterus. Qark, Rumpf, and Ries, were among the first to advocate the
extensive operation of removal of the iliac glands along with the uterus
and appendages. The results of this method have, however, been dis-
appointing. The immediate mortality is very great and recurrence is
just about as frequent as in other less radical procedures. There is a

26 ORIGINAL ABSTRACTS.

great difference of opinion between various operators regarding the
time of metastasis in cancer of the cervix. The writer evidently now
adopts the view advanced by Cullen and Winter that metastasis occurs
comparatively late in the disease. When the operable glands are
involved according to the studies of Schauta, only thirteen per cent show
no involvement of the upper or nonoperable glands. Consequently,
when there is extension of the cancerous process to the glands, the
outlook is not at all hopeful even with a so-called radical operation.

In view of these findings, the author now limits his operative inter-
ference to a thorough local extirpation of the uterus and adnexa, includ-
ing the upper portion of the vagina and the greater part of the broad
ligaments and parametrium. The abdominal route is preferred to the
vaginal, on account of the better opportunity to get well out on the
broad ligaments. c. g. p.

OBSTETRICS.

By WILLIAM HORACE MORLEV, Ph. B., M. D., Ann Arbor, Michigan.

DBMOMSTRATOR OF OBSTBTRICS AKD GTNSCOLOCT IM TMB UMITBIUITr OV MICHIOAN.

AND

WALES MELVIN SIGNOR. M. D., Ann Arbor, Michigan.

ASStSTAMT IN OSSTBTRICS AND GTNBCOLOGY IN THB UNITBRSITT OF MICHIGAN.

CAESAREAN SECTION.

Olshausen {Zentralblatt fiir Gyndkologie, 1906, Number I)
reports his results in one hundred eighteen cases. This report is sup-
plemental to one made by him in 1902 {Deutsche Klinik, Band IX), an
abstract of which appeared in iljt $^0utan anb Surgton for February,
1904, page 81. In his one hundred eighteen cases Olshausen sum-
marizes the indications as follows:

Contracted pelves,

91 cases

7 "
6 "

4 **
4 "
2 *'
2 **
2 "

UrCiampsia,

Myomata,

Carcinoma uteri.

Fixation of vagina,

Nephritis,

Vitium cordis.

Stenosis of vagina and cervix,

Among the cases of contracted pelves w^ere those of the rachitic type
most often seen. Seventy-one of the ninety-one cases were due to
rachitis. The remaining twenty cases were distributed as follows:
Five generally contracted, five obliquely contracted, two transversely
contracted, two pseudoosteomalacic, three skoliotic, one kyphoskoliotic
and two contracted or narrowed from exostoses. In eclampsia the
author prefers Caesarean section to forceps or to version and extraction.
He further states that the use of morphia in eclamptic cases is danger-
ous to the fetus.

TREATMENT OF DIPHTHERIA. 27

His technique has not been radically changed since his last report.
He does not put as much faith in the course of the round ligaments in
the determination of the placental site, as he did formerly. It' can
usually be located from the injection of the uterine wall and from the
outpouching of either the anterior or posterior wall. Hemorrhage is
not to be feared as it is easily controlled after the cut edges of the
uterine wall have been brought together. In seven patients this oper-
ation was performed twice. In two three times and in three four times.
All these cases recovered. In his ninety-one cases of contracted pelves
Olshausen has only lost nine cases. w. h. m.

PEDIATRICS.

By ARTHUR DAVID HOLMES, M. D.,C. M., Detroit, Michigan.

THE UNCERTAINTIES OF EARLY DIAGNOSIS AND THE
NECESSITY OF EARLY AND VIGOROUS TREAT-
MENT OF DIPHTHERIA.

McMahon (Pediatrics, Number IV, 1905) says the death-rate in
Ontario as elsewhere is too high, and attaches much blame to faulty
or tardy diagnosis and late and half-hearted treatment. He gives as
causes of failure :

( 1 ) The physician's attention is not especially directed to the throat
and he fails to look at it and diagnoses something else ; by the time he
recognizes his error, the case is hopeless. The golden rule is "always
examine the throat of a sick child, no matter what its symptoms are."

(2) He examines the throat and thinks he has a case of tonsillitis
or coryza or croup to deal with, or that even if it is diphtheria it is so
mild that the old-fashioned remedies are sufficient for its cure.

(3) He fails to follow up a suspicious case and finds, when too
late, that the patient is in a desperate condition.

(4) He treats one amongst many children and fails to protect the
others exposed to contagion, by a preventive injection.

(5) He uses antitoxin, but is half-hearted and does not use enough.

(6) In cases of laryngeal diphtheria he uses antitoxin — perhaps in
large doses — ^but fails to make an early resort to accessory remedies,
such as calomel fumigation and intubation.

(7) He makes an early diagnosis, but puts off the injection of anti-
toxin until tomorrow or the day after.

The author says the diagnosis of diphtheria should be made at the
first visit if possible. He does not believe we should depend or wait
for a bacteriological examination. In every case in which there is even
a suspicion of diphtheria, give antitoxin at once and give it freely. If
bacteriological examination shows the presence of the diphtheria
bacillus, give an injection to each of the children of the household to
prevent the spread of infection. In laryngeal diphtheria the author

28 ORIGINAL ABSTRACTS.

treats his cases as follows : (i) Inject antitoxin (full doses) and fume
calomel under a tent (thirty grams an hour) until stenosis is relieved.
(3) Intubate early if symptoms demand. To have a low death-rate
one must be prompt, bold and fearless in his treatment. In specially
malignant cases he recommends twenty thousand to thirty thousand
units as an initial dose injected into the median basilic vein.

ORTHOPEDICS.

By IRA DEAN'LOREE, M.D., Ann Arbor, Michigan.

FIRST ASSISTAMT IN ftVSGBRY IN THB UNIVBRSITY OV MICHIGAN.

A CASE OF EXCISION OF THE HEAD OF THE HUMERUS
FOR CONGENITAL SUBACROMIAL DISLOCA-
TION OF THE HUMERUS.

John B. Roberts, M. D., of Philadelphia (American Journal of
the Medical Sciences, December, 1905). His patient was a boy age
three years who came to operation December 5, 1903. The condition
present was as follows: The head of the left humerus could be felt
under the acromial process. The humerus was firmly abducted with
the external condyle pointing forward. The elevation of the arm,
so far as voluntary movement was concerned, was impossible and
other movements restricted. He therefore decided to replace the head
by operation, resecting the head for false joint providing the former
method failed.

A vertical incision was made over the prominence of the head
below the acromion and the capsule opened. As the attempt failed, a
second incision on the front of the shoulder was made and carried
down to the deep layer of muscles. Combined efforts from the two
points gave no results.

He concluded that only a bloody and prolonged dissection would
expose the glenoid fossa; even if reduction resulted he might obtain
only a stiff joint, which was no better than the original deformity;
that excision of the head would give as good, if not a better joint, with
less risk.

The bone was sawed close to the head but in its removal the long
head of the biceps was severed. Both cuts were closed without drain-
age and the forearm supported by a sling.

Examination June i, 1905. The left arm was three-quarters inch
shorter than the right arm. Grating at the false joint with passive
motion. Rotation not so complete as on right side. Elevation of the
humerus restricted and scapula moves with it, if passive movement
is extensive. Humerus still rotates slightly forward. The patient
can touch the back of his ear and neck on the left side, put his hand
to his mouth, and can clasp his hands behind his back in the lumbar
region. The belly of the biceps stands out prominently in the middle
of the arm due, no doubt, to the division of its long head. He cannot

SUBSTITUTES FOR NITRATE OF SILVER. 29

lift the left hand over his head but could merely touch the occipital
region. He could put the left hand on the opposite shoulder and bring
the elbow nearly in contact with the ribs.

Doctor Roberts thinks a large proportion of these cases result from
intrauterine causes as many times they occur on both sides in the same
patient and in more than one child of the same family.

OPHTHALMOLOGY.

By WALTER ROBERT PARKER. B. S.. M. D., Detroit. Michigan.

PROFBSSOR OF OPHTBAUfOLOGT IN TMB UNIVBIISITY OF MICHIGAN.

PROTARGOL AND ARGYROL AS SUBSTITUTES FOR
NITRATE OF SIVER.

Doctor G. E. de Schweinitz (Ophthalmic Record, January, 1906)
expresses his views concerning the use of the newer salts of silver.

At one time this writer had employed protargol very freely as a
substitute for nitrate of silver but had found it comparatively unsatis-
factory and had abandoned its use. He had employed argyrol first as
a substitute for nitrate of silver in all forms of conjunctivitis, except
diplobacillus conjunctivitis, in the treatment of purulent conditions of
the lachrymonasal passages, in the management of infected cervical
ulcerations, and in the preparation of the conjunctival sac prior to
operations. In his earlier experiences he had been inclined to think
argyrol was a satisfactory substitute for nitrate of silver in various
conjunctival inflammations, and particularly in ophthalmia neonatorum,
but within the last year he had met with so many cases wherein it had
been necessary to abandon this agent and substitute nitrate of silver,
that his faith in the remedy had been seriously shaken.

The doctor was satisfied that nitrate of silver properly applied in
gonorrheal conjunctivitis of newborn babies and in gonorrheal conjunc-
tivitis of adults frequently was a more satisfactory remedy, although
he recognized its many disadvantages. He had been accustomed to
employ argyrol by the so-called immersion method, and continued so to
use it in certain cases, but not to the exclusion of nitrate of silver. He
thought the plan advocated by Bruns, that after its use for a few days
nitrate of silver should be applied once a day by the surgeon, and in
the meantime the conjunctiva should be kept flushed with argyrol, a
good one. In many cases of gonorrheal conjunctivitis he did not
believe that of itself it was as safe a remedy as nitrate of silver, and in
a certain number of cases it failed completely and nitrate of silver had
to be substituted. He continued to find argyrol useful as an adjunct
in many forms of conjunctivitis, particularly of mild type, and thought
it a satisfactory remedy for irrigating the lachrymonasal passages if
purulent discharge was present. He also continued to use it in cleaning
the conjunctiva, if there was hyperemia or slight discharge, preparatory
to operations on the globe. Taking his experience as a whole, he was

30 ORIGINAL ABSTRACTS.

satisfied that neither protargol nor argyrol represents in any sense a
satisfactory substitute for nitrate of silver in gonorrheal affections of

the conjunctiva.

* * * .

Note. — To use nitrate of silver to its best advantage requires per-
haps more skill and careful observation than the use of any single drug
in the armamentarium of the opththalmic surgeon; while nothing is
more simple than the directions for use of its substitutes. When prop-
erly used, nitrate of silver still holds its supremacy. Our experience in
the University clinic is in exact accord with that of Doctor de Schwei-
nitz.

OTOLOGY.

By R. bishop CANFIELD. A. B.. M. D., Ann Arbor, Michigan.

PKOVBSSOR OF OTOLAKYNCOLOGY IN THE UNIVBRSITY OF MICHIGAN.
AND

WILLIAM ROBINSON LYMAN. A. B., M. D., Ann Arbor. Michigan.

DBMONSTKATOR OF OTOLARYNGOLOGY IN TKB UNIVBRSITY OF MICIIIGAN.

A REPORT OF TWO CASES OF MASTOIDECTOMY SINUS

THROMBOSIS.

McKernon (Archives of Otology, Volume XXXIV, Number IV).
The first case was a male twenty-six months old, always healthy save
for an attack of acute otitis one year before. When first examined
there was a mucopurulent discharge in the external auditory canal,
examination of which showed staphylococcus infection. The tympanic
membrane was bulging and there was a small perforation in the
posterior quadrant. The temperature was 102° and the child was
rather drowsy. The t)mipanic membrane was incised and in twelve
hours the temperature was 100''. On the fifth day temperature rose to
103.2° and there were signs of mastoid involvement. The mastoid
was opened and a small amount of pus found in the antrum. For
several days the patient did well and the wound looked healthy except
in a small spot over the sigmoid groove in the region of the knee.
The temperature was 103°, the child restless and refusing nourishment.
The temperature the following day was 104.8° and the wound was
bathed in pus. A diagnosis of sinus involvement was made, the sinus
was opened and a clot removed, free hemorrhage obtained and the
child apeared stronger. For four days the temperature ranged between
103° and 100°. On the fifth day the temperature went to 104.2°. The
child was very restless and looked septic. A few hours later the hands
and feet became cold, the temperature reached 105° ; pulse 160. The vein
was ligated below the clavicle and resected to its exit from the skull.
It was found to contain a clot for nearly an inch below the skull. The
facial vein was also involved and nearly an inch was resected. The
wound closed and patient made an uninterrupted recovery.

DRAINAGE OF THE FAUCIAL TONSILS. 31

The second case was a female, age thirty, who ckveloped an acute
otitis twenty-four hours after a partial turbinectomy with symptoms
of a profound systemic infection. The tympanic membrane which was
bulging was incised. The discharge showed many streptococci and a
few pneumococci. The temperature was 102.2° and the mastoid tender.
The temperature remained about the same and on the third day the
mastoid was opened and found to be involved throughout. Within a
few hours there was a sudden rise of temperature to 103.8° and a
sudden fall to 98.4°. For six days the patient did well save for a slight
fluctuation of temperature. On the tenth day there was a sudden rise
to 103.8° with intense headache and marked variations of temperature
during the next twenty-four hours. Sinus involvement was diagnosed
but owing to the extreme weakness ol the patient operation was delayed
and stimulating treatment given for five days. On the sixth day the
sinus was opened, and a large clot found extending backwards from
the knee about two inches. In the lower part of the vein there was
disintegrated clot and pus. There the internal jugular was exposed,
ligated and resected. At the same time many suppurating glands were
renK)ved, the wound was sutured and the patient made a good recovery.
All specimens removed contained numerous streptococci. It is worthy
of note that in this case there were no chills, nausea, or vomiting.

From the subsequent history of the first case it is seen that it would
have been wiser to have resected the vein at the time the sinus was
opened, as there may be free hemorrhage at the bulb while the vein in
the neck still contains a thrombus. Doctor McKernon feels like ligating
the vein in all cases at the time of operation when the condition of the
patient will allow. r. b. c.

LARYNGOLOGY.

By WILLIS SIDNEY ANDERSON, M. D., Detroit. Michigan.
AmsTAirr to tub cmair ow lastnooloot in thb dbtkoit collboi ow mbdicini

THE LYMPHATIC DRAINAGE OF THE FAUCIAL
TONSILS.

George Bacon Wood (American Journal of the Medical Sciences,
August, 1905) has made a number of dissections of injected specimens
to show the Ijmiphatic drainage of the faucial tonsils. The fate of
microorganisms which have entered the parenchyma of the tonsils is
dependent upon two factors : First, the pathogenic potency of the germ
itself, and second, the vital resistance offered by the tissues to its
invasion. It has been proven that foreign bodies in the crypts can pass
through the epithelium into the interfoUicular tissue. The absorption
is probably due to the action of the muscles and the presence of the
lymph current.

' The author describes the different lymphatic chain of glands and
gives the regions they drain. The direction of the drainage from the

32 ORIGINAL ABSTRACTS.

tonsils as established by the study of the injected specimens is as
follows :

"The lymph vessels pass from the external portion of the tonsil
through the peritonsillar connective tissue, the pharyngeal aponeurosis,
and the superior constrictor of the pharynx, and one, two or more
fine vessels run obliquely in a downward, posterior, and outward course,
passing below the facial artery. Bending more posteriorly the lymph
vessels next run between the internal jugular vein and the stylohyoid
muscle, reaching finally the superior surface of an enlarged lymph
gland, placed just beneath the anterior border of the sterno-cleido~mas-
toid muscle, where it is crossed by the posterior belly of the digastric
muscle. The efferent vessels from this gland are generally two or three
in number, and pass into the neighboring glands of the internal jugular
group. Further anastomoses which connect the lower glands of the
internal jugular group with those receiving the tonsillar drainage form
a complete lymph channel, through which tonsillar lymph finally empties
into the jugular lymph trunk."

The author gives the name "tonsillar lymph gland" to the gland
placed external and slightly anterior to the internal jugular vein, and is
embedded in loose areolar tissue containing more or less fat. This
gland is especialy involved in infections from the tonsil.

DERMATOLOGY.

By WILLIAM FLEMING BREAKEY. M. D., Ann Arbor. Michigan.

CLINICAL PROFBSSOR OP DIRMATOLOGT AMD STPHILOLOGT IN THB UNIVBKtITY OP MICHIGAN.

ON THE INFLUENCE OF LIGHT IN THE PRODUCTION OF
CANCER OF THE SKIN.

Doctor James Nevins Hyde, of Chicago, Professor of Diseases of
the Skin in Rush Medical College, read a paper on this subject before
the Ann Arbor Medical Qub, November 8, 1905. The entire article is
published in the American Journal of the Medical Sciences for January,
1906, but the following abstract presents the salient points thereof.

The paper was a comprehensive discussion of the pathology, etiol-
ogy, prevalence, and mortality resulting from conditions beginning as
cancer of the skin, particularly with reference to the damaging effects
of solar light and :r-rays under certain conditions, and radiotherapy in
general ; also to the lesser prevalence and death rate from cancer in the
colored races and inhabitants of warmer countries, attributed to the
protection against ill effects of excessive light, afforded by the greater
pigmentation of the skin.

It is impossible to give, in the limits available, an adequate abstract
of the scope and value of the paper, illustrated with several paintings
and maps, supported by statistics, and presented in the interesting and

CANCER OF THE SKIN. 33

forcible style of the distinguished author. It should be read in full to
be appreciated.

Discussing the various forms of epitheliomata, "these all represent
variations of a single morbid process ... an invasion of neigh-
boring tissues through the avenue of the lymphatic spaces by epithelial
cells." Considering the causes of this change, which may reach a point
when destruction of life results, and noting the recent research work
on the subject conducted by scientific men in laboratories equipped and
maintained by generous private and public benefactions, "as yet, how-
ever, agreement has not been reached respecting the essential factors
in the genesis of this scourge of the human family."

"The chief causes of cancer heretofore assigned by writers on the
subject may be classed as follows : First, proliferation of the epidermis
proceeding from stray bits of the germinal layer separated in the embryo
from their proper attachments and included in the growing tissues
(Cohnheim) ; second, loss of equilibrium — ^pressure and counterpres-
sure — ^between the epidermis and the corium; third, disturbance of
equilibrium between waste and repair; fourth, congenital tendency to
reversion of epidermal cells to a simpler and undifferentiated type ; fifth,
parasitism." There are many and seductive reasons for searching for

a parasite as the cause of cancer It is difficult to conceive

that the human body in so large a proportion of cases, without intro-
duction of a foreign element, can evolve a growth of such malignant

potency A decided reaction, however, seems to have set

in against the tide which bore in the direction of parasitism of cancer.

. . Many of the bodies which it was once believed would prove to
be parasites are now known to be irregular cell inclusions. . . .
Various considerations, which need not be cited in full, have for the
time lessened the belief of scientific men in the hypothesis of parasitism
in cancer.

"Carcinoma of the sailor's skin," also described by Unna, in which
cases the ears, the cheeks, the temples, the backs of the hands, and of
the fingers first become mottled and pigmented, nonpigmented islands
of skin later developing between the freckles, with thickening, roughen-
ing, and comification of the horny layer follow, and eventually, as in
xeroderma pigmentosum, the sebaceous glands become hypertrophied
and indolent cancerous growths of the "rodent ulcer" type form. There
is both hyperkeratosis and acanthosis, and conical homy taps push
downward into the corium; the lymph spaces of the lattei^ become
largely dilated ; the mast cells multiply, fissures form, and finally papil-
lary cancerous growths furnish flabby ulcers which refuse to heal.

These instances of malignant cancer occurring obviously as a result
of exposure to light justify the inquiry whether all cutaneous cancers
are not influenced in their origin and career by the actinic rays. It
would be venturesome without strong proof to make a broadly affirma-
tive answer to such a question ; but the condition of skin which makes
epithelioma more than possible certainly predisposes to its occurrence.

34 ORIGINAL ABSTRACTS.

The question can be better put by asking whether actinic rays of light
unfavorably influence, not all, but certain sensitive skins at definite
ages of the body in the direction of the epitheliomatous metamorphoses?

It is to be remembered that pigmentation, especially hyperpigmenta-
tion, admittedly furnishes a valuable protective screen for the body.
The dark skins of the Asiatic and the African possess for them a great
protective value against heat and light. The Albino, without trace of
pigment either in the skin or the choroid coat of the eye, is notoriously
feeble of body and short-lived. Hektoen states that black rats are more
resistant than gray, and gray rats than white to anthrax. In this con-
nection it is interesting to note that Gaylord and his colleagues in study-
ing Jensen's adenocarcinoma obtained their remarkable results after
experimentation with white mice only. The researches of Loeb, Gru-
ber, Dubois and others on the orientation of plants and animals throw
some light on this question. They indicate that heliotropism is influ-
enced largely by the more refrangible rays of light; . . . that at
a constant intensity light operates as a continuous source of stimulation ;
. . . chemical rays playing upon the sensitive and unprotected skin
produce in order — first, hyperemia; second, pigmentation; third, atro-
phy ; fourth, cancerosis. The first two changes are obviously protective
in character.

The action of the Finsen light upon the skin produces a reactive
hyperemia, though the technique of its application requires that the
area to be treated should be made as exsanguine as possible to permit
the passage of rays to the skin. The action of the ,r-rays upon the
cutaneous surface is similar to that of the ultraviolet frequencies.
. . . The hyperemia is followed by well-marked pigmentation, more
conspicuous in some cases than in others. Later, in the results of
actinic ray bombardment, atrophy may result, the overstimulated pro-
toplasm losing its vitality, the cells and their nuclei shrinking while
phagocytosis, as in other cases, disposes of the epithelial cells. But
hyperkeratosis, and finally cancerosis may occur. The .r-ray produc-
tion of cancer of the skin reported by Mendes, Da Costa, White,
Bowen, Pusey and others is established by other incontrovertible evi-
dence. Fortunately the beneficent use of the rays far outranks the
exceptional catastrophe in which a disastrous result is produced.
Doctor Ormsby has noticed that patients who burn in sunlight are
burned by ^-rays. The beneficial effects of all these rays occur when
the stimulation is pushed to the point of cell shrinkage and not farther.

The doctrine that light is capable of exciting in animal tissue a
series of changes which may terminate fatally is not inconsistent with
the facts of science. Beneficent as they are shown to be in much that
relates to both the genesis and conservation of life, heat, light, and
electricity, interchangeable modes of motion have each a stroke where-
with slowly or swiftly they may destroy that life."

Following are the doctor's conclusons :

(i) The skin of the human body in a certain proportion of indi-

DIET IN EPILEPSY. 35

viduals, and in those only, is hypersensitive to the action of the actinic
rays of the spectrum.

(2) This hypersensitiveness may be exhibited in the production of
either hyperemia, pigmentation, telangiectasis, atrophy, hyperkera-
tosis, or cancerosis of the skin, or by all at times in a determined order
of succession.

(3) In the form of childhood cancerosis, known as xeroderma pig-
mentosum, pigmentation, telangiectasis, atrophy, hyperkeratosis, and
cancerosis of the skin resulting from exposure to rays of light, are
exhibited early in life, instances of this disorder being exceedingly rare.

(4) Pigmentation, telangiectasis, atrophy, hyperkeratosis, and can-
cerosis of the skin occur in adults much more frequently than in child-
hood, reaction to the play of actinic rays of light upon the surface being
chiefly determined after the middle periods of life have been reached.

(5) Physiological pigmentation of the skin in the colored races
seems to furnish relative immunity against cancerosis of that organ.

(6) The colored races apparently suffer less than the whites from
cancer of other organs than the skin. This relative immunity may be
due to the protection from actinic rays of light furnished by the pig-
ment of the integument.

NEUROLOGY.

By DAVID INGLIS, M. D.. Detroit, Michigan.

PROFISSOS or KIRVOUS AND KBNTAL DISHASSS IN THB DBTKOIT COLLBCB OF MBDICINB.

AND

IRWIN HOFFMAN NEFF, M. D., Pontiac. Michigan.

ASSISTANT PHYSICIAN AT THB BASTBRN MICHIGAN ASYLUM.

THE DIET IN EPILEPSY.

RoSANOFF (Journal of Nervous and- Mental Disease, December,
1905, Volimie XXXII, Number XII). The writer quotes authorities
in proof that certain articles of diet may cause a material change in the
syndrome of epilepsy. The paper is founded on eleven cases. The
results were obtained from five experiments, a definite number of
epileptics being placed on a prescribed diet, and accurate clinical
observations taken.

His results are summed up as follows : "Experiments one and two
proved that the effect of a mixed diet in epilepsy differs in no way
from that of a vegetable diet containing the same quantities of proxi-
mate principles. Consequently any lingering belief that animal iood
has any effect as such is to be definitely discarded. Experiments three
and four prove that the quantity of proteids in the diet has a decided
influence on the manifestations of epilepsy. If it i<' either above or
below the indispensable minimum the severity of the disease is
increased. Experiment five shows that if the diet of an epileptic is
made to contain a large excess of proteid and practically no carbohy-

36 ORIGINAL ABSTRACTS.

drates, so that the organism is compelled to use proteid material in
place of carbohydrate material, the number of convulsions increases
enormously and there is a general aggravation in the physical and
mental condition of the patient."

In conclusion the author advances a theory as follows : "That just
as the organism of the diabetic is unable to properly utilize carbohy-
drates, so the organism of the epileptic cannot take care of proteid
material as it is taken care of by the normal organism."

The therapeutic indication, he believes, is clear, and he expresses
it as follows : "Carbohydrates and fats are to a certain extent capable
of replacing the proteids in the diet. The epileptic j)atient, then, should
receive the largest amount of carbohydrates and fats that he can
assimilate without inconvenience, and the smallest amount of proteids
which is compatible with the preservation of the nitrogenous equi-
librium ; that is to say, the amount of nitrogen ingested with the food
must not be allowed to fall below the amount excreted, for then the
thing is overdone, a condition of proteid starvation is established, the
general health of the patient suffers, and his disease becomes
aggravated." i. h. n.

THERAPEUTICS.

By DELOS LEONARD PARKER, Ph. B., M. D.. Detroit, Michigan.

LBCnmiR OH MATBRIA MBDICA IN THB DBTROIT COLLBGB or MBDICIMB.

THE PRESENT STATUS OF SERUM THERAPY.

Ezra Read Larned, M. D., in The Therapeutic Gazette for Sep-
tember, 1905, discusses the subject of serum therapy. He first sepa-
rates the different sera into two groups as follows : ' Curative sera and
diagnostic sera. He further classifies sera according to their efficacy
as curative agents.

In the first group he places those whose efficacy has been demon-
strated beyond reasonable doubt, such as antidiphtheric, antitetanic,
antiplague, antistreptococci and serum for exophthalmic goitre.

In the second group are sera whose value appears likely or possible,
but in support of which there is not yet sufficient evidence to warrant
their inclusion in Class I. These contemplate hay-fever, antityphoid,
antitubercle, antirabic, and antivenene sera, and tuberculin.

In the third group are those sera whose value is questioned by a
majority of observers. These are antipneumococcic sera, antiscarla-
tina sera, antidysenteric sera, antivarioloid sera, antitoxin for cerebro-
spinal meningitis, serum for rheumatism, serum for syphilis, and sera
for anthrax, cancer, and leprosy.

Of the curative sera Doctor Lamed states that antidiphtheric serum
justly holds the highest place, and if used early and in sufficient quan-
tities can be counted on to overcome every case of the disease.

Of antistreptococcic serum not so much can be said. On the whole

CLINIC IN PSYCHIATRY. 37

the Doctor thinks the result obtained from this serum has been dis-
appointing. This result may be caused by the circumstance that pure
streptococcic infection is rare as compared with mixed infection. Where
the infection has been purely streptococcic the result has been good.

Antitetanic serum gives good results when used early and in large
quantities. Professor Ehrlich is quoted as saying that initial doses of
thirty cubic centimeters or more followed by frequent subsequent doses
of ten or twenty cubic centimeters may be depended on to produce
results satisfactory in character. Authorities differ as to the mode of
administering this serum. Among the methods mention is made of
subcutaneous, intravenous, intraneural, intracerebral and intraspinal
by lumbar puncture. The use of dried antitetanic serum as a dusting
powder in dressing suspected wounds is recommended.

Antiplague serum is said to be of positive value when given in large
doses — from sixty to one hundred and fifty cubic centimeters, or even
three hundred cubic centimeters, preferably intravenously.

In exophthalmic goitre the specific seruhi is said to be so encourag-
ing in results that its use is to be recommended.

Hay-fever serum the doctor thinks is of great but of uncertain
value. The remedy may be administered hypodermically but better
results are usually obtained by having the patient himself apply the
serum to the nasal mucous membrane by means of a dropper when
irritation is noticed. In the use of this serum the good effects are not
long maintained.

Tuberculin is spoken of as an experimental product and antitubercle
serum as being worthy of more extended trial. Serum for rheuma-
tism, secured from horses treated with streptococci, isolated from the
throat of the rheumatic sufferer, gives promise of being valuable.

The sera whose standing as curative agents has not been established
are mentioned above.

EDITORIAL COMMENT.

THE NEW CLINIC IN PSYCHIATRY AT THE UNIVERSITY

OF MICHIGAN.

The first University Psychopathic Hospital and Clinic established
in America for the observation, care, and treatment of persons afflicted
with incipient insanity, and for borderland cases which cannot be strictly
regarded as insane, although manifesting various phases of mind dis-
turbance, is now in operation as a component part of the medical equip-
ment of the University of Michigan, under the directorship of Doctor
Albert Moore Barrett, late pathologist of the Massachusetts Hospital
for the Insane, located at Danvers, and assistant in neuropathology in
the Harvard Medical School. The governing power of the institution

38 EDITORIAL COMMENT.

is vested in a joint committee, whose appointment rests with the Univer-
sity Regents and the executive bodies of the various state asylums for

the insane.

♦ * *

The institution was created by enactment of the legislature of 190 1.
A supplementary act of the legislature of 1905 established relationship
between the hospital and asylums, and henceforth the two forces will
render combined service in the management of the new institution.
Another provision of the law invests the director of the Psychopathic
Hospital with the title of pathologist to the several asylums, and pro-
fessor of neuropathology in the medical department of the University.
In the capacity of pathologist a requirement contemplates definite
knowledge by this official concerning the medical conduct of the
asylums throughout the state, exacting frequent visits for the purpose
of encouraging the medical staffs to pursue careful scientific study of
the various forms of mental disease peculiar to the inmates. As pro-
fessor in the University the director is required to impart instruction
in clinical psychiatry and conduct the laboratory for psychopathic
research which was founded in connection with the hospital, the main-
tenance of which is insured by an annual appropriation of five thousand
dollars granted by the legislature.

m n^ m

The objects sought to be attained by founding the institution con-
template more accurate investigation relative to the nature and causes
of insanity. The idea is to make the new acquisition a central patho-
logic institute which will* afford not only expert skill in nervous diseases
by reason of cooperation with the asylums of the state, but possess,
in consequence of University connection, the additional advantage of
specialists in every branch of medicine. It will give asylum physicians
opportunity to pursue research work at the clinical laboratory, and
qualify students to render intelligent service as asylum physicians or
general practitioners. It will exert influence in the direction of cre-
ating a correct public sentiment regarding psychopathic ailments and
of promoting rational ideas concerning the prevention of such diseases.

* 4t :|c

The Psychopathic Hospital is especially designed and equipped for
the study of acute cases of mental disturbance. It has accommodation
for forty patients — twenty of each sex. This limited number permits
the alienists to exercise close observation of every subject committed
for treatment. The clinical laboratory affords apparatus for conducting
elaborate investigation bearing on the phenomena of mental disease,
and the study of any anatomical material supplied by the various
asylums will be pursued according to methods afforded by the most
modern neuropathological technic. There will likewise be installed in
the building a complete hydrotherapeutic apparatus modeled after the
design of Doctor Baruch, together with apparatus for administering

CLINIC IN PSYCHIATRY 39

electrotherapeutic treatment whenever this particular therapeusis is
indicated.

4t * *

The Psychopathic Hospital affords a place where persons may be
sent for short observation pending opinion as to the necessity of com-
mitting them to one of the state asylums, or as to whether preliminary
treatment at 'this institution will obviate the necessity for such commit-
ment. Thirty-eight patients have already been registered and applica-
tions for a number of others are under consideration. Thirty-two of
the patients were transferred from the state asylums at the opening of
the hospital, and the remainder are voluntary patients or those com-
mitted as private and county charges. In addition to the director there .
is constantly in attendance the resident physician, Doctor George Milton
Kline. Cases are continually presenting in which the question must
be determined whether the condition is onp of neurasthenia or of more
serious transitional form of mental disturbance, and physicians through-
out the state are advised that patients may be sent to the institution
according to three processes.

♦ * *

(i) In cases where application shall be made under the statute to
send persons claimed to be insane to one of the asylums in the State
of Michigan, the Judge of Probate, before whom said application is
pending, may require the assistance of three competent and skilled
physicians who shall investigate the condition of said person and report
the same to the Judge of Probate in writing and if said Judge of Pro-
bate upon investigation ascertains that there are present in *the con-
dition of the patient such features as render detention in a psychopathic
hospital for a brief period advisable as a precautionary or curative
measure, or if from such investigation said Judge of Probate shall be
of the opinion that the case requires the services or treatment of special-
ists in the treatment of diseases other than those of the nervous system,
he shall pass an order directing thaf such patient shall be transported
for treatment to the Psychopathic Hospital of the University of Michi-
gan. If the patient shall continue insane after any such special treat-
ment he may be removed to and confined in such asylum of the State
of Michigan as the Probate Judge may decree in his order of committal
to the Psychopathic Hospital.

4c 4t 4t

(2) In case the Superintendent of either of the asylums for the
insane shall be of the opinion that the condition of mind of any person
confined in such asylum is such that it might be advisable that the
patient be sent to the Psychopathic Hospital he shall cause such person
to be conveyed thereto. If such patient shall be restored to sanity while
in the said institution he shall be discharged, but in case such patient
shall be found incurable, the Superintendent of the University Hospital
shall cause said person to be returned to the asylum from which said
person was received, the charges for the care, maintenance and trans-

40 EDITORIAL COMMENT.

portation to be paid by the county or by the state, depending upon
whether the patient is a county or a state charge.

♦ ♦ 4k

(3) Persons may ccwnmit themselves as voluntary patients under
the same provisions as apply to such commitments to the state asylums.
The exact charge for maintenance cannot be determined at this time,
but will depend upon the average per capita cost for maintaining the
hospital, and will vary with the number of patients present in the hospi-
tal at such time. It will be somewhat higher than for the care of patients
in the state asylums, but will be kept as low as is consistent with proper
treatment and the purposes for which the Psychopathic Hospital was
established. It will probably be about the same as is charged in the
other hospitals of the University, which at present is about seven dol-
lars and fifty cents per week. Private patients may be admitted at any
time under any of the foregoing provisions. In such cases the joint
board in control of the Psychopathic Hospital has fixed the rate of
fifteen dollars per week, and requires the friends of each private patient
to furnish a bond in the penal sum of one thousand dollars, on substan-
tially the same conditions, so far as applicable, as those required by the
Michigan asylums for the insane. There shall be paid by such private
patient, or by his or her friends, at the time such patient is admitted, as
an advance pa>Tnent toward the support of such patient, the sum of
fifty dollars.

ANNOTATIONS.

THE TREATMENT OF SARCOMA WITH MIXED TOXINS.
CoLEY, in a contribution to the recent meeting of the Southern Sur-
gical and Gynecological Association, detailed his experience with a mix-
ture of the toxins of erysipelas and the bacillus prodigiosus in the treat-
ment of sarcoma. While the doctor had, until recently, employed the
mixture only in such cases as were not amenable to surgical treatment,
his success with a large variety of cases has led him to advocate its
administration in all forms of the disease wherein primary surgical
operations have been performed. Very minute doses should be
employed in this class of cases — only large enough to produce slight
reaction. Before inaugurating radical measures, such as limb amputa-
tion, it is well as a final resort to employ the toxins, since in a number
of patients disappearance of the tumor and consequent recovery resulted
from their administration. In arriving at his conclusion the author
observed the recovery of twelve patients, eight of whom were alive and
well for from three to six years after treatment. Eight of the above
cases were of the round-cell variety; two of the spindle-shape; while
the tissue of the remaining two patients was not subjected to micro-
scopic examination. But three of these cases were personal. How-
ever, Coley has detailed the result of the treatment in thirty-four cases
under his direct supervision, with which he experienced but five

TREATMENT OF MAL DE MER. 41

reverses — recurrence of the tumor and subsequent death. While the
demise of this quintet is to be regretted, it would seem to furnish proof
conclusive of the correctness of the diagnoses. The cases under
Coley's personal study, and those which he has been able to observe out-
side his own practice, embodied (i) round-celled, (2) mixed-celled, (3)
spindle-celled, and (4) endothelioma.

PEDAL CHARACTERISTICS OF DIFFERENT PEOPLES.
Comparative study of the foot in barefoot and shoewearing peoples
is detailed by Doctor Hoffmann in a late issue of the Quarterly Bulletin
of the Medical Department of Washington University, The relative
length of the foot in either class is practically the same, and in both
classes the form, function, and range of motion, up to the time of shoe
adoption, are markedly similar. Deformation and inhibition of function
follow the inauguration of shoewearing. The pedal inheritance of the
shoewearer's progeny, so far as form is concerned, is synonymous to
the heritage acquired by the offspring of barefoot races, the natural
symmetry, however, being altered after encasement in modem foot-
wear. The theory is advanced that the strength and usefulness of the
foot is not dependent on the height and shape of the longitudinal arch,
and breaking and lowering of the arch to the degree of flat-footedness is
rarely resultant from weakness at this point. Moreover, no relation-
ship exists between the gait and the height of the arch.

PHYSIOLOGIC FUNCTION OF THE PITUITARY BODY.
Anent the various theories that have been expounded regarding the
origin of sleep, a recent contribution by Doctor Alberto Salmon, to the
Italian Medical Congress, is of vital interest. The opinion of this
scientist is that an internal physiologic secretion from the pituitary
gland produces somnolence. He further expresses the idea that the
bromine contained in the pituitary structure is the active agent in sleep
production, and cites the experience of the profession in the employ-
ment of the glandular extract in insomnia to substantiate his hypothesis.
Somnolence is often associated with certain pathologic conditions of the
gland, and the reverse may be true, since in many cases wherein tumor
is present, in Graves' disease, in cases of poisoning with consequent
inhibition of the secretion, and in many other conditions, including
senility, insomnia is the prevailing symptom. While sleeplessness is
said to result from an insufficient flow of the pituitary secretion, an
increase of the fluid by the ingestion of such toxic drugs as pilocarpine
invariably produces a condition of profound sleep.

THE MECHANICAL TREATMENT OF MAL DE MER.

A MECHANICAL dcvicc lately invented by Doctor Carl Brendel, a
Russian physician, promises relief from seasickness to individuals not
proficient in nautical accomplishments. While the condition has been
combatted more or less successfully by the administration of drugs and

42 EDITORIAL COMMENT.

chemicals, not many remedies of a mechanical nature have been offered
to the maritime traveler, and hence announcement of the latest preven-
tive will be accorded consideration. The novelty is in the form of a
chair, the seat, arms, legs, and back of which are freely movable. The
idea of the designer is that a counteraction of the long pitching move-
ment of the sea-going vessel, by the short up and down and occasional
backward movement of the chair — the motive power of which is fur-
nished by a small electric motor — tends to overcome the seasickness.
The inventor does- not claim for his chair immunizing properties, nor
does he even venture that it will effect permanent cure, but those who
have had opportunity to test its virtues declare that a few moments of
repose in the chair offer relief from the unpleasant symptoms.

CONTEMPORARY.

PHYSICIANS AND PHILOSOPHERS.

[professor CHARLES WILLIAM SUPSR, OP OHIO UNtVRRSITT, IN POPULAR SCIENCE MONTHLY.]

Although the initial assonance of physician with philosopher
is purely accidental, it is nevertheless a fact that philosophy and the
healing art or medical science have been closely associated with each
other from their earliest beginnings. It cannot but be regarded as a
singular coincidence that for two and a half millenniums physic and
philosophy, the practitioners of the healing art and the real or professed
lovers of knowledge, have been more or less intimate friends. At the
beginning they seem to have found themselves in each other's company
almost by chance; then by a sort of elective affinity like that which
often springs up between persons of opposite sex whose paths in the
ordinary course of events incidentally crossed each other, to have
discovered that they could make the rest of the journey together to
reciprocal advantage.

Herodotus, the Father of History, was a native of Halicarnassus,
and Hippocrates, the Father of Medicine, his younger contemporary,
first saw the light on the island of Kos, only a few leagues distant.
Born in the same year with Hippocrates was the philosopher Diogenes,
of Apollonia in Crete, whose few literary remains not only attest his
interest in human anatomy, but also furnish proof that he early came
under the influence of the Ionian thinkers. Though never regarded
as a physician, but only as a philosopher, he tells us in one of the very
brief fragments that have been preserved that the veins of the human
body are divided into two branches ; that they pass through the abdom- '
inal cavity along the backbone, one on the right side, the other on the
left, into the legs y and that two branches pass into the head. He then
goes on to describe the course of the blood-vessels and their ramifica-
tions as far as the ends of the toes, the fingers, and so on. It may
safely be assumed from this fragment that Diogenes gave much atten-
tion to the structure of the human body.

PHYSICIANS AND PHILOSOPHERS. 43

In the southwestern portion of Asia Minor, the disciples of
Asclepias or iEsculapius had several therapeutic establishments, and
it is in connection with these that we discover the first signs of what
may be called the healing art in the entire ancient world.

It was especially the priests of the temples of Kos and Knidos who
cultivated a primitive and simple medical science in connection ynth
their service of the god. In this part of Asia, also, philosophy took
its rise. For not only was Hippocrates a philosopher as well as a
physician, but the same affirmation can be made of a considerable
number of Greek thinkers. Diogenes has just been mentioned. More-
over the two lines of investigation were often parallel in other parts
of the ancient world. Empedocles who was a full generation older
is supposed to have been a physician. Pythagoras, who lived still
earlier, though perhaps not a physician in the strict sense of the word,
gave, according to tradition, no little attention to the laws of health
and formulaited a mmiber of precepts supposed to be conducive to its
preservation. Plato, though not a special student of the healing art,
shows in many passages of his Dialogues, a considerable degree of
familiarity with the subject. Aristotle was the son of a physician and
was indebted to his father not only for much of his knowledge, but
also for his interest in natural history; while his pupil Theophrastus
is regarded as the father of medical botany. Among the Romans we
find Pliny paying a good deal of attention to facts or supposed facts
in the realm of medicine. The same thing is true of Seneca and still
more of Vitruvius, though it would perhaps be as far astray to call
him a philosopher as a physician in the strict significance of the terms.
Toward the latter part of the second century we are carried back again
to Asia Minor to find in Galen of Pergamus, not only a distinguished
writer on philosophical subjects, but a man whose reputation as a
physician is fully equal to, if not greater than, that of Hippocrates,
notwithstanding that he was a man of less native capacity. It may
be confidently affirmed that Hippocrates, Celsus and Galen represent
the entire healing art until modern times. With respect to Cornelius
Celsus, who lived in the reign of Tiberius and who occupies an impor-
tant place in the history of ancient medicine, it mu.«t be said that it
is uncertain whether he was really a physician. It is rather more
than probable that he was a savant. On the other hand, the question
is raised. Why would any one but a practical physician compile a
medical work? Could any other person do it successfully? Another
singular fact that has added to the difficulty of defining Celsus' posi-
tion is that even as late as the age in which he lived nearly all the
physicians in Rome were Greek freedmen. At any rate the work of
Celsus at once sprang into prominence, and though it is only part of
an encyclopedic compilation, nothing else remains at the present day.
As*is the case with not a few other works of antiquity, its connection
with modem times hangs by the slender thread of a singfle manuscrpit
from which all later copies have been made. This portion of the
encyclopedia of Celsus has also an important historical value since it

44 ^ MEDICAL NEWS.

gives brief sketches of more than seventy physicians who had lived
before his time and had attained a certain degree of eminence. It
had not escaped his observation that only persons of mediocre ability
are loth to admit errors, while the reverse is true of genius, since there
still remains a large residuum of truth in its possession.

[TO BE CONTINUED.]

MEDICAL NEWS.

A PHYSICIAN GRANTED PATRONYMIC APPELLATION.

Doctor Charles Beylard Nancrede, Professor of Surgery in the
University of Michigan, recently petitioned the Probate Court of the
County of Washtenav^^ for a change of his name, and he will hence-
forth bear the appellation of "Charles Beylard Guerard de Nancrede."
The application recounts the information that the grandfather of the
petitioner bore the cognomen of "Paul Joseph Guerard de Nancrede,"
but discarded the "de" at the time of his naturalization as an American
citizen; that the father, who was bom in 1799, was baptised "Thomas
Dixey" and never utilized the family patronymic "Guerard de Nan-
crede," simply abridging the name to "Nancrede." Restoration of the
name to its original form was desired for family reasons.

THE DEMISE OF DE WECKER.

Baron De Wecker, of Paris, who died recently, was seventy-three
years of age. Through his death the world has lost one of the "Fathers
of Ophthalmology" and one of the greatest ophthalmic surgeons of
his day. .He was oculist to Napoleon III, and to the Spanish Court,
and was also von Graefe's chief of clinic and associate of Artt and
Jaeger. He succeeded Desmarres in Paris and introduced the ophthal-
moscope in France. The French government made him Grand Officer
of the Legion of Honor, and he received decorations from nearly every
crowned head of Europe,

MINOR INTELLIGENCE.

Our printing house is recovering from the effects of the recent
printers' strike and succeeding numbers of this journal will be issued
promptly.

The Hungarian government has awarded one thousand kronen
to Professor Kohut, of Konigsburg, for his prize essay on the treat-
ment of trachoma.

According to report the original copy of Harvey's paper on the
"Circulation of the Blood" was sold recently for £30. The manuspript
was written in 1628.

MINOR INTELLIGENCE. 45

The Western Penitentiary of Pennsylvania is threatened with an
q)idemic of smallpox. A prisoner who has been incarcerated for over
a year has mysteriously contracted the disease, and every precaution is
being exerted to protect the nine hundred fifty inmates of the prison.

The government contemplates the erection of a $400,000 hospital
for the Army and Navy. Doctor Louis de Clermont, of Washington,
has secured a site of over six hundred acres of ground in Illinois, and
a structure sufficiently large to accommodate three thousand patients
mil be erected thereon.

Minnesota has a law compelling physicians to report to the
register of deeds of their county, all accidents in which the victim is
disabled for a period of two weeks or longer. Failure to comply with
the enactment is punishable by a fine of one hundred dollars or impris-
onment for a period of six months.

An interesting case of premature maternity is reported from
Bristol, Tennessee. The mother is a colored girl, ten years of age, a
native of Virginia, and the infant weighs eight pounds. It is said
that chances for its survival are excellent and that the mother has
experienced a complete recovery from the early parturition.

Spring Beach, a suburb of Seattle, Washington, is to have a new
$30,000 sanatorium. A four-story structure is contemplated, and as
the promoters have already secured one hundred acres of land, ample
grounds are assured. The institution will afford accommodation to
five hundred patients, and will be under the supervision of a staff of
fifteen physicians.

Brooklyn has a novel institution in the form of a public library for
the blind. Inasmuch as raised letter books are quite expensive, and as
few blind persons can afford indulgence in them, the library is a very
welcome acquisition to the educational system of the city. Most of the
volumes deal with nature or light emotional subjects, as sightless indi-
viduals prefer this variety to works of more profound type.

The war department has provided for the establishment of a chair
of military hygiene at the West Point Military Academy. The cadets
will receive sufficient medical knowledge to enable them to care for
troops from a hygienic standpoint, and to administer relief in superficial
injuries. The founding of the chair was doubtless prompted by the
remarkable results obtained by Japanese military surgeons in the late
war.

The German Rontgen Society has issued an inaugural volume of
proceedings, detailing the work of the first congress of .r-ray workers.
The book is divided into five parts enumerating the various features
of the meeting. The first section is merely a compilation of the physi-
cians who were in attendance; section two is devoted to exhibits;
section three contains the papers read and the discussions thereon;
and sections four and five are devoted to a history of the organization,
and the publication of communications.

46 MEDICAL NEWS.

Professor Terriani estimates that eighty per cent of the child
criminals of Italy owe their vicious instincts to unsuitable environment
and insufficient educational advantages. He further states that thirty
per cent of the criminals of the kingdwn have not yet reached legal age,
and that of this number eighty-five per cent are thieves.

Efforts are being exerted toward the establishment of a medical
college for the United Provinces of India, as a memorial of the visit of
the Prince and Princess of Wales to the Peninsular. The question has
long been agitated and it is probable that matters have at last reached
a focus, as each province is endeavoring to outdo the other in the matter
of support.

The consolidation of the Medical and Surgical Monitor and the
Centred States Medical Magazine has been effected at Indianapolis,
the new publication being known as the Central States Medical
Monitor, Doctors S. E. Earp and S. P. Scherer will comprise the
editorial staff. The Monitor is the latest acquisition to the field of
independent medical journalism, and we wish it success.

The National Association for the Study of Epilepsy has announced
its intention to award a prize of $300 for the best original paper on the
"Etiolc^ of Epilepsy." Essays must be submitted for approval before
September i, 1906, as the prize essayist will be announced in November.
Physicians desiring information regarding the award may communicate
witii the president of the association, Doctor W. P. Spratling, of Sonyca,
New York.

The twenty-ninth annual meeting of the American Dermatological
Association was held in New York City on December 28, 29 and 30,
1905. The following officers were elected for the ensuing year: Presi-
dent, Doctor Milton B. Hartzell, of Philadelphia; vice-president,
Doctor T. Caspar Gilchrist, of Baltimore; secretary-treasurer, Doctor
Grover W. Wende, of Buffalo. Cleveland was designated as the meet-
ing place foV 1906.

In accordance with an order from the Commissioner of Immigration
of the port of New York, saloon and second cabin passengers will
henceforth be subjected to examination by the government physicians.
Heretofore the order affected only steerage passengers, but owing to
rejected immigrants taking advantage of legal inadequacy by returning
as saloon passengers the regulations in regard to such persons were
made more stringent.

Boston has a new hospital for the treatment of diseased horses,
dogs, cats, and other domestic animals. The institution is to be
equipped in the most approved fashion — operating rooms, exercising
paddocks, private wards, and baths being stipulated in the architect's
plans. A free clinic will be conducted weekly for animals belonging
to the poorer classes. The hospital is under the direction of Samuel
F. Wadswords, M. D. V., a graduate of the Harvard Veterinary
School.

INTERNATIONAL CLINIC. 47

Paul Revere, the Revolutionary patriot, according to the follow-
ing announcement taken from an old copy of the Boston Gazette and
Country Journal, must have been a dentist : "Whereas, many persons
are so unfortunate as to lose their Fore-teeth by Accident and other-
ways, to their great Detriment, not only in Looks, but speaking both
in Public and Private : — This is to inform all such that they may have
them replaced with artificial ones, that looks as well as the Natural &
answers the end of Speaking to all Intents, by Paul Revere, Goldsmitji,
near the head of Dr. Clarke's Wharf, Boston. All Persons who have
had false Teeth fixt by Mr. John Baker, Surgeon Dentist, and they
have got loose (as they will in time), may have them fastened by the
above who learnt the Method of fixing them from Mr. Baker."

RECENT LITERATURE.

REVIEWS.

COAKLEY'S LARYNGOLOGY.*

The popularity of the two preceding editions is suflScient proof of
the value of this work. In its third edition it has been revised, enlarged
and brought completely up-to-date. Due to its completeness and to
its ccMnpact form it serves equally well as a text-book for students and as
a reference book for practitioners and specialists. The most important
revision in this last edition is that of the chapter on the "Diseases of the
Accessory Sinuses." This has been entirely rewritten and gives very
clearly the author's standpoint upon this very important division of
the specialty.

Throughout the work is well written and well illustrated and offers
a consistent and satisfactory exposition of its subject matter.

*A Manual of Diseases of the Nose and Throat. By Cornelius G.
Coakley, A. M., M. D., Professor of Laryngology in the University and
Bellevue Hospital Medical College ; Laryngologist to Columbus Hospi-
tal, et cetera, New York. New (third) edition, revised and enlarged.
In one i2mo. volume of 594 pages, with 118 engravings and five colored
plates. Qoth $2.75 net. Lea Brothers & Company, Publishers, Phila-
delphia and New York, 1905. - R. b. c.

INTERNATIONAL CLINICS.*
The latest volume of this well-known series gives us as usual a valu-
able collection of sound practical papers, with a few theoretic or sugges-
tive ones. Among the former may be mentioned a very useful article on
"Radiothcirapy," by George C. Johnston; one on the "Symptomatic
Treatment of Tuberculosis," b); Noble P. Barnes ; "Membranous Colic,"
by Alexander McPhedran ; "Addison's Disease," by Edward F. Wells ;
"Cancer of the Bile-Duct," by F. Parkes Weber and E. Michel ; "Frac-

48 RECENT LITERATURE.

ture of the Patella," by J. Sherman Wainwright ; "Ethyl Chlorid Anes-
thesia," by Thomas D. Luke. Richard Kretz gives a succinct account
of "Cirrhosis of the Liver," in its anatomic relations. The articles of
Albert Robin, on the "Action of Metallic Ferments on Metabolism and
Pneumonia," and Professor Teissier on "Opotherapy in Renal Insuffi-
ciency," are interesting. Sanger Brown has a thoughtful article on the
"Early Stages of Acute Poliomyelitis," so often overlooked in practice,
and there are others in Ophthalmology and Rhinology. John W. Wain-
wright's article on "Serum Therapy" is brief to the danger point. If
vaccination is to be includedin such an article it would seem worth
while to give some explanation of unusual views that appear, such as
the one that "true animal vaccine" and "variola vaccine" are different,
or are distinguished in practice, or that "pulp consists of proliferated
epithelium."

On the whole the volume is not quite up to the standard of some of
its predecessors, but well deserves the continued popularity acquired by
the series. G. d.

*A Quarterly of Illustrated Clinical Lectures and Especially Pre-
pared Original Articles, et cetera. Edited by A. O. J. Kelly, A. M.,
M. D., Philadelphia. Volume III. Fifteenth Series, 1905. J. B. Lip-
pincott Company.

HAREMS TEXT-BOOK OF PRACTICAL THERAPEUTICS.*

The eleventh edition of this work, enlarged, revised and largely
rewritten is before the profession. Among the changes that have been
made in bringing out this edition the changing of the doses of drugs to
conform to the new Pharmacopeia is the most important. To the physi-
cian this is a labor-saving provision, to the patient a guarantee that his
medicines are efficient and safe, and to the student a path that leads m
the way he should go.

The volume contains two sections, one dealing with drugs, remedial
measures and foods, the other with the use of drugs, in treating disease.
The book has the good points of its predecessors and several other
good points in addition.

Hare's Therapeutics has come to take on some of the characteristics
of a government report. A new edition is looked for yearly and the
opinions and the conclusions expressed are viewed as coming from one
in authority. D. L. p.

*A Text-Book of Practical Therapeutics, with Especial Reference
to the Application of Remedisil Measures to Disease and their Employ-
ment upon a Rational Basis. By Hobart Amory Hare, M. D., B. Sc,
Professor of Therapeutics and Materia Medica in the Jefferson Medical
College of Philadelphia, Physician to the Jefferson Hospital, et cetera.
New eleventh edition, enlarged and thoroughly revised to accord with
the eighth decennial revision of the United States Pharmacopeia, 1905.
In one octavo volume of 910 pages, with 113 engravings and four
colored plates. Qoth, $4.00, net; leather, $5.00, net; half morocco,
$550, net. Lea Brothers & Company, Philadelphia and New York.

MOSKS GLNN.

A PROFESSIONAL MEDICAL JOURNAL.

VOLUME XXVIII. FEBRUARY. 1906. . NUMBER II.

ORIGINAL ARTICLES.

MEMOIRS.

THE LIFE AND CHARACTER OF MOSES GUNN.

A. M., M. D., LL. D.*

By C. B. G. de NANCR^DE, A. M., M. D., LL.D., Ann Arbor, Michigan.

PROnSSOIt OF SUKGERT AND CUNICAL SUKGBXT, AND DIKBCTOR OF TMB SURGICAL CLINICS, IN
THB UNIVSRSmr OF MICHIGAN.

Mr. President, Members of the Faculty, Students of the Department of
Medicine and Surgery, Ladies and Gentlemen:

While perhaps it is appropriate that to the present incumbent of the
Chair of Surgery has been deputed the task of presenting to you a few
of the salient facts in the life and character of the first Professor of Sur-
gery in this institution, I cannot but feel that it is most unfortunate that
one so little associated with him personally, had to be selected. This
man, to whom the medical school owes so much, who in every sense of
the word was one of our Founders, can hardly have justice done him by
one who never worked with him in those early days when, as he taught
others, he learned himself, day by day, how the facts of medical science
could best be conveyed ; for, as you will see, he was practically without
training as a teacher when at one bound he was called upon to fill two
of the most important chairs in the Medical Department of the Univer-
sity of Michigan, and that too, in a school depending entirely for its
future success upon the ability of its untried faculty. How well he
succeeded, it Will be my endeavor to show you, and to point out those
qualities by means of which this success was achieved.

The subject of our memoir was born in East Bloomfield, New York,
the youngest of the four children of Linus Gunn and Esther Brunson.
His parents were of Scotch ancestry, Moses taking after his father
physically, the latter being a tall and powerful man. Like other men

♦An Address delivered before the Faculty and Students of the Medical Department
of the University of Michigan, on "Founders' Day," February 22, 1906.

50 ORIGINAL ARTICLED.

who have achieved eminence, as a child Doctor Gunn showed some of
those traits of character which explain in a great measure his success,
especially his love of mechanics, and a distinctly quick and logical miad
that swne anecdotes which I shall relate will prove.

The family homestead being located on the main stage route from
Rochester to Canandaigua was so conveniently situated that, encouraged
by the reputation the Gunns had for hospitality, travelers often stopped
there, and clergymen and other men of education made short stays with
them. Doubtless, the wits of the young Moses were sharpened and
stimulated by frequently listening to the conversation of educated and
cultured men, this in some measure accounting for his nimbly-acting
mind. One day, when only a little fellow, he was tinkering at a home-
made vehicle, and a brother teasingly asked him why he did not hitch
up the old dog and make him pull the wagon. Moses replied that he
was too old. The brother retorted *'I am going to kill this dog, for he
is too old and useless, and'-^^^t^ ujilgo^tw^h room," when instantly
Moses flashed back, "iMg^are going to Kill^exery thing that is too old,
you had better go in amlp kill your grandmotK

Again, dissatisfiecft witWDfiiT 8^€l9ft7^skedi why he had been so
called, and being told B^^is mother that it wWthe name of his grand-
father, who was a courte8^g/g^mjsybl« p}<^j;gatieman, whom his parents
hoped to have him emulate, hetlUiLRljf aiTswered, "that is a good reason
but I could just as well have emulated him without his name." When
barely five, one Thanksgiving day he was overlooked when some deli-
cacy was handed around. Turning to his aunt he reproachfully said,
"Whatevr that uhis you didn't pass it to me/' At once the dish was
handed him when with sly humor he said, "Oh, never mind, I do not
twint it, only I like to have folks pass me things when I am around."

Like straws which prove which way the wind blows, these anecdotes
show that the quickness of perception, power of logical deduction, and
sense of humor which characterized his after life, even at this early age,
were unusually developed.

I would especially ask for the attention of the undergraduate stu-
dents to the brief remarks I shall make concerning Doctor Gunn's boy-
hood. Although for a time, as will be seen, seriously handicapped by
ill-health, enjoying no special advantages over his fellows, yet, availing
himself of every opportunity, however unpromising it appeared, he
actually converted what would have been obstacles to others, into oppor-
tunities for planting his feet on the lowest rungs of the ladder of
success. As Longfellow says:

"All common things, each day's events.
That with the hour begin and end.
Our pleasures and our discontents,
Are rounds by which we may ascend.

We have not wings, we cannot soar;

But we have feet to scale and climb
By slow degrees, by more and more,

The cloudy summits of our time."

LIFE OF MOSES GUNN. 51

Sent early to school, from twelve to fifteen years of age he had for
his tutor a young theological student, a resident in his father's house.
Finally, entering the Bloomfield Academy he continued his studies
there until attacked by a serious illness, his behavior during which
showing how his strong will could compel his suffering body at any
cost to obey that which approved itself to him as right. Thus, during
part of this illness he rode to school, at times suffering so much that
he could only permit his horse to walk, while the pain in his side made
it almost impossible for him to sit upright in the saddle, but, recog-
nizing the evils of such an attitude in the young, he sternly resisted the
inclination.

Undismayed by his illness he displayed much fortitude. Instead of
succitmbing and abandoning the hope of completing his education, he
accomplished what he could and devoted himself to the recovery of his
health. The execution of this project requiring extreme care for two
years and finally a change of residence and a sea voyage, shows the
mental fibre possessed by this youth, and the discipline of patience
required must have served to mould his character with finer lines and
into more compact form.

A few months after his return from his voyage he commenced the
study of medicine under Doctor Edson Carr, of Canandaigua. That
the same keenness of observation, and accurate correlation of the facts
thus obtained were as prominent traits of character during his student
days as they had been in his childhood is proved by a remark of Doctor
Carr evidencing the opinion this shrewd observer had early formed of
Gunn. Walking side by side one day, the wind blew a corner of the
doctor's cloak over Gunn's arm, when the pupil remarked, "How proud
I should be if your mantle could fall upon my shoulders." Gazing
keenly at him for a moment Doctor Carr replied, "My boy, you will
wear a greater mantle than mine." Doctor Carr enjoyed a high repu-
tation as an operator and was greatly admired by his pupil, yet on one
occasion after assisting his preceptor in the performance of an
operation, Gunn remarked to a friend that if he ever met with a similar
case he would treat it after a radically different method. Years after,
in a number t>f instances, the truth of his youthful previsions was jus-
tified by his results. Such independence of judgment coupled with a
well-balanced mind such as Gunn possessed, was one of the chief
reasons for his early success ; when sure he was right, he did not hesi-
tate to contravene professional conventions.

A former student of Doctor Carr's, our own Corydon L. Ford, then
Demonstrator of Anatomy in Geneva Medical College, on his occasional
visits to his old preceptor was struck by Gunn's "earnestness in what-
ever he undertook," and especially "his enthusiastic devotion to the
study of anatomy." Upon the observations thus casually made by Ford
depended the after life of young Gunn. I am anxious in thus selecting
from the mass of material at my disposal the really epoch-making
events of Doctor Gunn's life, that students may recognize how at an/
period of life a man as he really is, not as he wishes to appear, is often

62 ORIGINAL ARTICLES.

subjected to an unsuspected scrutiny upon the results of which, all
unknowingly to himself, his future in great measure may depend.

In October, 1844, entering the Geneva Medical College, Gunn was
at once conceded to be a man of unusual promise, and Dr. Ford's
originally high opinion was so justified that, when the latter's health
prevented him from conducting his work in practical anatomy, he
entrusted to the young undergraduate the instruction of his classmates,
thus giving the opportunity Gunn needed. Ford afterwards ^aid that
Gunn in performance of these duties evinced so much aptness and skill
in instructing others, that his future success as a teacher and operator
were clearly foreshadowed. Even at this time young Gunn, encouraged
by Ford, and given a chance to show his capacity as a teacher, when
talking over the future, indulged the hope that he and Ford might at
no distant time be associated in a medical school, Ford as the Anatomist,
Gunn as the Surgeon. To paraphrase the Shakespearean saying, the
wish became the father to the thought, and the thought induced Gunn
to bend all his energies to translate his thought into a reality.

The quickness with which Gunn availed himself of an opportunity,
which most would have failed to make adequate use of, is shown by
a circumstance which occurred just before his graduation. The college
received, too late to utilize for the session, an unclaimed body for dis-
section. There being no means for preserving it Doctor Gunn was
allowed to use the body for purposes of instruction. He packed the
body in a large trunk, and receiving his diploma on Tuesday, left his
home for Ann Arbor on the Monday following the day of his gradua-
tion. Two weeks after leaving home he made his arrangements and
commenced lecturing on anatomy, which proved so successful, that in
succeeding years he repeated this course accompanied by dissections
and demonstrations. This was the first course on anatomy ever given
in Ann Arbor, and probably the first in Michigan. I am credibly
informed that these lectures and demonstrations were given in the
basement of the old court house which occupied the site of the present
building.

In July, 1849, Doctor Gunn was appointed to the chair of Anatomy
in the University of Michigan to which was added the Professorship
of Surgery early in 1850. In 1854 it was deemed advisable that Doctor
Gunn should teach only Surgery, and in June of this year Doctor
Corydon L. Ford was appointed to fill the chair of Anatomy. Thus
at last the youthful dreams of these two enthusiastic men were realized,
one taught Anatomy and the other Surgery in the same medical school.
The year previous to his appointment by the Board of Regents — 1848 —
Doctor Gunn married Jane Augusta Terry, only daughter of J. M.
Terry, M. D. The fruits of this union were four children, the eldest
of whom, Glyndon, was accidentally drowned in the Detroit river in
the summer of 1866. The remaining three children survived their
father.

In 1853 he changed his place of residence from Ann Arbor to
Detroit, where he remained until called, in 1867, to Rush Medical Col-

LIFE OF MOSES GUNN. 63

lege. From 1853 to 1867 he made two weekly trips to Ann Arbor,
during each session, to deliver his lectures on Surgery. Recognizing
that he should pattern his teaching after the best models he determined
to spend the winter of 1849 and 1850 in visiting the medical schools
and hospitals of New York, Philadelphia, and Boston, before delivering
his first course of lectures at Ann Arbor to the entering class consisting
of ninty-two students. I cannot refrain from quoting some of Doctor
Gunn's keen observations upon the difference in the mediqal atmos-
pheres respectively of Philadelphia and New York. He justly con-
sidered that Philadelphia then was, from the medical standpoint, the
Paris of America, and while this visit preceded my student days some
twenty-six years, in my time this was equally true. "There is a medical
atmosphere which is really refreshing," says he in a letter to his wife.
"You see the M. D.'s in this City of Brotherly Love have a kind of.
hospitality peculiarly their own." This remark was evoked by the
hospitality that men who had won great names in medicine accorded
this young aspirant for fame, such men as Charles D. Meigs, Joseph
Pancoast, John Neill, Professor? Mutter and Homer, all insisting upon
his accepting numerous social invitations and making him free of their
homes, merely because he was a member of the same profession.
Doctor Gunn then goes on to say in this same letter, "The New Yorkers
have a good deal of suavity, but the politeness of the Philadelphia
doctors is extended in the way of generous hospitality, and almost
every member of the profession that I have met seems to be imbuecf
with the same disposition. As I said before, Philadelphia contains a
medical atmosphere that is most refreshing, and if you could see the
way the doctors do it up here, you would admire the profession more
than you now do."

Urged by patriotic and humanitarian motives, and recognizing the
fact that, in modern parlance, the battlefield was one of the surgeon's
laboratories, he joined the Army of the Potomac on September i, 1861,
as Surgeon to the Fifth Michigan Infantry, remaining in the^service
until failing health compelled him to resign in July, 1862. Returning
to Detroit during a three-weeks' leave of absence, in December and
January, 1861-62, he crowded into this time his quota of lectures at
Ann Arbor and rejoined at Alexandria. Leaving this place with his
regiment Doctor Gunn served through the Peninsular Campaign until
his resignation in July, 1862.

Like many other men at that time he was an enthusiastic admirer of
General George B. McClellan, and with generous indignation expressed
in his letters his opinion of the politicians who, he said, marred the
General's plans. This was in accordance with his character, for if,
after what he considered sufficient deliberation, he arrived at an opinion,
to this he would cling most tenaciously, notwithstanding valid argu-
ments to the contrary. This trait of character I frequently observed in
our mutual intercourse. Both as an illustration of his capacity of
unburdening his mind in well chosen language, as well as to call atten-
tion by his burning words to the unrewarded heroism of the profession

64 ORIGINAL ARTICLES.

you medical students are about to enter upon. I shall quote a portion
of one other letter.

"You say that Mrs. R. complains that Surgeons are never alluded
to after a battle. No; why should they be? Poor, benighted souls;
did anyone dream for a moment that a surgeon's field had aught of
glory about it? No; the glory consists of carnage and death. The
more bloody the battle, the greater the glory. A surgeon may labor
harder, must labor longer, may exhibit a higher grade of skill, may
exercise the best feelings of our poor human nature, may bind up many
a heart as well as limb, but who so poor as to do him honor? There is
ho glory for our profession. We may brave the pestilence when all
others flee; we may remain firm at our posts when death is more
imminent than it ever was on the battlefield ; but who sings our praise ?
Does the world know who the physicians were who fell at Norfolk
when yellow fever depopulated that town ? Does it know who rushed
in to fill their places? And of those who survived can it designate
one? Did they survive to receive fame? Yet those men were braver
than the bravest military leader, for theirs was bravery unsupported
by excitement or by the hope of fame. No ; there are none so poor as
to do us reverence. And thank God there are few of us so unsophis-
ticated as to expect it."

While this is lamentably too true, yet it is the glory of our profes-
sion that unlike the soldier, striving neither for glory nor for promotion,
the medical man simply does his duty because it is his duty.

I cannot refrain from citing an incident in order to impress upon
the minds of medical students that the welfare of a patient should be
paramount to every other consideration; Although what I shall relate
happened upon the battlefield, as has just been pointed out, the same,
nay a higher kind of courage is often demanded when facing disease,
as is daily done by the rank and file of the profession. In a skirmish
against one of the hill tribes on the frontier of India, an officer was
severely wounded in advance of his troops as dusk was coming on.
One of the large arteries was wounded and death from hemorrhage
was imminent. The surgeon of the party ran forward and in com-
parative shelter compressed with his fingers the artery, arresting the
bleeding. While the location of the fire of the enemy shifted, it con-
tinued. Doubting the efficiency with which he was compressing the
artery, night having now fallen, the surgeon deliberately lit a match
instantly causing a hail of bullets to fall around him, and then finding
his patient in great danger of being wounded a second time, arranged
an efficient makeshift to take the place of his fingers in arresting the
bleeding, picked up his patient at the greatest risk to his own life,
carried him to the rear, tied the severed artery, and saved him ! What
is the rush forward with victorious thousands compared to such an
act of heroism? I am glad to say that this British surgeon received
the Victoria Cross for Valor, but who receives any recognition, as Gunn
says, when deliberately facing death from loathsome disease?

Although much of interest remains concerning Doctor Gunn*s life

LIFE OF MOSES GUNN. 55

at this time which would be instructive and interesting, enough has
been said to indicate most of his characteristic mental traits, and now
it behooves us to briefly consider what additional qualities rendered
him so remarkable as a teacher. Although from the purely intellectual
standpoint the physique of a teacher should play no part in his success,
even now\ a stalwart frame, fine voice, an impressive and commanding
presence, coupled with enthusiasm, will go far towards securing the
attention and winning the confidence of scholars, after which the mental
pabulum offered is accepted by them with but little question.

When Doctor Gunn commenced teaching, in this country an
instructor had first to be a man whom manly men could admire, mere
intellectual force alone being decidedly at a disadvantage, having
slowly to win attention instead of compelling it. Gunn and men of his
stamp commanded attention and confidence, the students unconsciously
placing themselves en rapport with an instructor so • bounteously
endowed physically. The same was true of almost all the great
teachers of Surgery of Doctor Gunn's generation, such men as the
elder Gross, Hunter McGuire, David Yandell, Edward H. ^^oore and
others I could mention.

1 shall never forget how I was impressed by my first sight of
Doctor Gunn twenty-three years ago. Sauntering along the street a
half block away I saw the striking figure of a man considerably over
six feet in height, well proportioned, with an erect military carriage,
clad in a snugly-fitting, carefully-buttoned-up black frock coat, his head
surmounted by a high black silk hat. He had long gray side whiskers,
a heavy drooping moustache, and curling gray hair resting upon his
coat collar. He frequently raised his gold-rimmed eyeglasses to note
the architectural peculiarities of each house he approached, every street
incident, every passer by, and then the eyeglasses were allowed to
swing from their long gold chain to be again quickly readjusted should
anything seem worthy of attention. Altogether he presented an impres-
sive figure of' a man of physical and mental power, of one who must
investigate everything presented to his senses, who quickly observed,
classified his impressions, deciding upon the respective merits and
proper relation even of passing events, a man of an alert and enthu-
siastic temperament, ready and eager to digest new ideas, yet one whose
judgment restrained his zeal within due bounds. The essentials of
these impressions were instantaneously photographed upon my mental
retina and I subsequently found them to be accurate. A man thus
opulently endowed by nature and trained by a life of continuous
effort to excel, could not fail to command at the very outset the atten-
tion and confidence of any audience, and to exert an actively compelling
influence over them.

The modern student can only have a faint conception of the stress
laid, forty or fifty years ago, upon the manner, as well as the matter
of a lecture. At the present time, almost any form of expression is
permissible that the speaker believes will convey his ideas, so the
naked truth, or what is too common, truth clad in ill-fitting, actually

56 ORIGINAL ARTICLES.

distorting verbal garments, disgusts or fails to impress the hearer, or
more often, an entirely wrong idea is conceived. Slang, catchwords,
anything will do? Qear cut thoughts neither will be nor can be
expressed in crude, slovenly language. A careless, loose mode of
expression, no effort being made to clothe ideas in appropriate and
decorous speech, is always an evidence of ill-digested, loose thought;
nay more, it inevitably leads to less and less effort being made to think
or observe clearly.

Gunn and his contemporaries recognized and avoided these pitfalls.
Careful deliberation was employed in deciding exactly what informa-
tion was to be given, but an equal effort was put forth in securing
fitting language to convey with exactness the facts to be considered.
Let none think that it was pedantic or an unnecessary refinement to
mentally alter or recast phrases before giving them verbal utterance,
because this is a necessary part of any good lecturer's work. Gunn
and his successful contemporaries understood the necessity of so lec-
turing that the audience did not become dulled by constantly listening
to nearly the same phraseology employed to convey different ideas, and
thus lose all the subtler differences in scientific values because of the
lack of nice discrimination in the language employed by the speaker.
Happy is he who at the outset possesses a large vocabulary, but he
must never lose an opportunity to add to his store of words. A lec-
turer who conscientiously searches out the exact word or phrase to
correctly convey a given idea will find his mental vision wonderfully
clarified, and will rarely have to answer questions propounded by his
mystified class. Let me give you an illustration of the plan pursued
by another of our great teachers of the past. Doctor Francis Gumey
Smith, Professor of Physiology in the University of Pennsylvania, when
I was a student there. Two hours of the evening preceding the lecture
was spent in consulting authorities and refreshing his mind as to experi-
ments, et cetera. At i o'clock the next afternoon he went to his room
at the medical school, read over the stenographic report of this same
lecture delivered during a previous course, saw that the vivisections
demonstrated what he desired, or, that the experimental apparatus was
working properly, and then, the last three-quarters of the hour pre-
ceding his 5 o'clock lecture were devoted to selecting the most fitting
language to employ in recapitulating the previous lecture, and for the
lecture about to be delivered.

Can you wonder that it was a rare treat to listen to such a speak-
er's smoothly-flowing sentences, and that we exactly apprehended what
he strove to teach us? And this expenditure of five or six hours in
the preparation of each lecture was not only made when Doctor Smith
commenced teaching, but after twenty-five years of practice. Let no
one think that it is unnecessary to thus cut, alter, and recast phrases,
for to such precautions do I attribute much of the successful teaching
of years ago.

No experienced lecturer thinks it beneath him to search until he
finds the exact word or phrase to convey a given idea, even if he has

LIFE OF MOSES GUNN. 57

to restate that which he has already presented more obscurely to his
audience. I firmly believe that if some of the present opponents of
so-called didactic lectures as a means of conveying scientific knowl-
edge, could have listened to the really great teachers of the past, much
of their opposition would be withdrawn. But to attain such skill is
no easy task, even for those starting with unusual endowments, the
aspirant for laurels as a speaker cannot indulge in careless, inaccurate
language in ordinary conversation, or in his correspondence. These
faults were conspicuously absent in Doctor Gunn. I have read many
letters of his, portions of some of which you have listened to, and
the same happy lucidity that illuminates his more pretentious writings
characterizes his family correspondence. He thought clearly and took
the trouble to always employ that phraseology which compelled his
readers or hearers to apprehend him exactly. Doctor Gunn as a lec-
turer was so clear in his rapid, emphatic statements that he impressed
his auditors with his thorough mastery of his subject. He was a
scholarly and accurate speaker, one of the best examples of the old
method of preparing and delivering didactic lectures. Punctuality in
the lecture room was one of his articles of religion. His superb figure
and commanding presence at once centered the attention of the class
upon him. Doubtless some of his facility as a speaker and writer was
due to his connection as editor with the Monthly Independent and its
successor, the Peninsular and Independent Medical Journal, His pub-
lic clinical work was his chief delight and his reputation was largely
due to these lectures and his operative skill, his contributioris to lit-
erature, as we shall see, unfortunately being few indeed. Full of fun
and anecdote, which he often most skilfully employed to fix in the
minds of his auditors certain facts he was discussing, he was never
known to indulge in an unclean joke or allusion, such being utterly
abhorrent to his nature. If the occasion demanded some mention of
the errors of another physician, this was done in the kindest, most
unobtrusive manner. He was absolutely considerate of others in a
consultation and was never known to speak unkindly, professionally,
of another physician. He was a most skillful diagnostican, and arrived
at his conclusions with startling rapidity, so much so that he was
unjustly accused of being careless. Exactly the reverse was true, but
his accuracy of observation and the rapidity of his mental processes
explain the ease and speed of his diagnoses. As a clinician he was
above everything painstaking. Every step of an operation was care-
fully traced out; every possible . complication and its remedy forseen
and provided for; every instrument or appliance was mentally — as it
was later actually — set aside in its place; everything was accurately
mapped out. This studious observation of minute details secured the
remarkable success which crowned his efforts. His frankness in deal-
ing with patients was conspicuous. He never made disingenious or
misleading statements, nor would he consent to deceive his patients as
to their true condition. He was free from any taint of dishonesty with
patient or practitioner. On one occasion a consultation was being

58 ORIGINAL ARTICLES.

held over an obscure case, Doctor Gunn being present. When asked
his opinion he replied: "Gentlemen, I have practiced surgery long
enough to learn that it is a wise thing in a doubtful case to be modest
in expressing an opinion. I do not know what this tumor is and I
think it had better be let alone." Duty well done, his whole duty to
his patient, seemed his sole guiding motive. When once asked in a
note handed to him while lecturing, "What is a doctor's best road to
success," he replied with great earnestness and solemnity, "Young
man, your best road to success is to deserve to succeed."

His judgment as an operator was excellent. He possessed a cool
head, steady, iron muscles, which yet could wield a scalpel like an
artist's pencil, and above all, a most minute and accurate knowledge of
anatomy. With such endowments and that supreme self-confidence
born of past successes, and full preparedness for any emergency, Gunn
was a bold, rapid, brilliant, and at the same time neat operator.
Although the boldest of the bold when occasion arose, as we have seen
he was in reality most careful of the indispensable details without
which disaster so often must come. He never ceased to feel the burden
of responsibility and when operating would permit of no levity of
manner. As he once said to another physician, "I never can, although
I often wish I could, divest myself of anxiety and responsibility in
dangerous, or more especially troublesome cases; they keep me in a
painful state of concern." His mechanical ability was pronounced;
as some one said. "His instrumental paraphernalia, straps, and splints
and bandages, alw^ays fitted the variety of the species, and not merely
the class and order."

As a writer Doctor Gunn wielded a facile pen which lacked neither
force nor point. He employed nice discrimination in the selection of
words, so that he was a remarkably clear writer, while his style, instead
of consisting of the short, staccato sentence, which is the only style
some men can employ to make themselves understood, was a decidedly
flowing one, pleasant to read, yet most lucid. He possessed to an
eminent degree that indefinite something we call grace of diction. He
thought so rapidly and accurately that of necessity he was compelled
to employ a large number of words, and in perusing his articles the
reader usually overlooks the exceptionally large vocabulary employed,
and wonders why he understands so readily sentences that sometimes
contain over fifty words. His thorough reading and speaking knowl-
edge of German, and an excellent acquaintance with French, added to
the range of his literary acquisitions, hence the appropriateness of his
illustrations and citations, when rapidly pouring forth a flood of
language, was remarkable.

It is much to be regretted that the great Chicago fire destroyed the
manuscript of a work on Surgery which Doctor Gunn had nearly
completed. Upon the Programs you will find the titles of the papers
and addresses which, with numerous editorials published in the journals
of which he was editor, and discussions of the papers of others read
before the American Surgical Association, comprise all the literary

LIFE OF MOSES GUNN. 59

remains bequeathed to us by Doctor Gunn. Of their value none can
doubt, and especially those upon the "Philosophy of Certain Disloca-
tions of the Hip and Shoulder, and their Reduction." As Doctor Senn
remarked, "He left us no encyclopedia of medicine but his little
pamphlet of less than twenty-five pages contains more than many
others have compiled in bulkier form."

During the winters of 185 1-2-3 Doctor Gunn made numerous dis-
sections which proved that the untorn portions of the capsule in dis-
locations of the shoulder and hip were the cause of the characteristic
attitudes assumed by the limbs, and furthermore were the true obstacles
to reduction. He further demonstrated that the return of the dis-
located bone to its socket "can be easily effected by putting the limb
in such a position as will effectually approximate the two points of
attachment of that portion of the ligament which remains." Doctor
William H. Reid, of Rochester, New York, on May 8^ 1850, had
described a method of reduction by manipulation which was essentially
one procedure which is yet employed, but he failed to point out cor-
rectly the obstacles to be overcome and the mechanism of the reduction.
Doctor H. J. Bigelow, of Boston, was doubtless familiar with Reid'?
method which had been published, in connection with a controversy
excited by Reid's original paper, in the Boston Journal about 1851-2.
Doctor Bigelow continued to reduce dislocations on the cadaver before
the medical class by a method of manipulation from 1854 until 1861,
believing with Reid that the muscles caused the fixed attitude of the
limb, et cetera. Then, as Doctor Bigelow says, "In the spring of 1861,
having been lead to expose a joint, the luxation of which had been
the subject of a lecture, I was agreeably surprised to observe the sim-
ple action of the ligament, — a simplicity which subsequent experience
has confirmed, and which strikingly explains the phenomena observed
in the living subject." Had Doctor Bigelow deigned to cast his eyes
over the Peninsular Journal of Medicine, Ann Arbor. 1853-4, Volume
I, pages 95-100, he could have learned all the facts that he needed to
know, which had been deliberately sought for and discovered by the
obscure young western surgeon, not accidentally seen, as Doctor
Bigelow states was the fact with regard to his own discovery.

There can be no question that to Gunn belongs the priority of dis-
covery as to the causes of the characteristic attitude of limbs dislocated
at the shoulder- and hip-joints, what the obstacles to reduction are, and
the simple principle of relaxing these unyielding structures by position
and inducing, without force, the bone to retract the course it pursued
when escaping from the stocket. Although everything that Gunn
wrote was of distinct value, his reputation as an investigator and
original writer must depend upon this admirable piece of work.

In 1856 Geneva College conferred on him the Honorary degree of
M. A., and Chicago University that of LL. D. in 1877. At the time of
his death Doctor Gunn was an active member of the American Surgical
Association, of the American Association of Genito-Urinary Sur-
geons, of the Illinois State Medical Society, of the American Medical

60 ORIGINAL ARTICLES.

Association, of the Chicago Medical Society, and had been a member
of several of the Congresses of American Physicians and Surgeons.
He served as surgeon on the active and consulting staffs of a number
of charitable institutions, notably the Cook County Hospital, Saint
Joseph's Hospital, Saint Luke's Hospital, and especially the Presbyterian
Hospital, intimately connected as this was with the Rush Medical Col-
lege, where he held the Chair of Surgery for nearly twenty full years.

On the fourth of November, 1887, after an illness of some weeks,
this noble physician passed beyond the veil to his well-earned reward.
He was a lifelong, consistent and faithful member of the Episcopal
church, belonging to the old-fashioned high church school. Despite
the materialism of many of his fellow-doctors, he said, "I often doubt
terribly, but I say to myself, I looked this thing all over once, I went
through the arguments and I decided that the immense balance of
testimony was in favor of Christianity, and I cannot take time to go all
over it again."

Doctor Gunn's tenderness to his child patients and their love in
return for him was very striking. His fondness for animals, flowers
and natural beauty was strongly developed and freely indulged. Unlike
too many physicians, he did not permit his profession to absorb and
narrow him, if for no other reason, lest his powers as a practitioner
and teacher should be crippled thereby. In addition to the study of
foreign languages and the literature of our own tongue, Doctor Gunn
was at one time a most enthusiastic and well-informed astronomer,
thus providing himself with a resource which, when drawn upon, could
bear him away irom his daily worries, rest his mind, and serve to
elevate his thoughts from material to spiritual things. Well would it
be if every one of us would strive for ^me form of knowledge and
culture alien to that of our profession. Doctor Gunn was fond of and
shone in society as a conversationalist, now one of the nearly lost
arts.

I have apparently striven thus far to present you an idealized
picture of a flawless man, which none of us believes to exist. It
remains for me in my peroration to point out some of the glaring
defects inseparable from a character such as I have endeavored to
depict. He was imbued rather too strongly with a sense of self-respect,
allied to, but something far nobler, than conceit. Conceiving the idea
that he was born to govern in many things he sometimes aspired to
command outside of his legitimate sphere. He was intolerant of argu-
ment on almost any subject, and often did scant justice to his opponents.
He could be bitingly sarcastic, and resort to ridicule, which, as I once
told him, was not argument, and totally out of place in a scientific
discussion. He was prompt and sharp in his dealings with the blunders
and shortcomings of anyone who failed to do what he considered was
their best. In some things he was radical to the point of being revo-
lutionary. He never catered for popularity by shading his expressions
of opinion, but struck as l^ard as it suited him, without regard for
consequences. In his determination to be absolutely honest in the

LIFE OF MOSES GUNN. 61

expression of his opinions he sometimes appeared harsh, when he was
really actuated by the best motives. While tenacious of professional
opinion, he never claimed to be able invariably to correctly diagnose
the innumerable conditions presented for his consideration, often
quoting to the students, the saying, "if your foresight was as good as

your hindsight you would not make so many mistakes by a

sight." He was an ideal consultant, never by word or action criticizing
the attendant before the patient ; if he had anything uncomplimentary
to say, it was said to the physician, as it always should be, in private.

To sum up, then, Gunn was a notable and noble figure of a man,
one of whom the profession and especially this school has good reason
to be proud. An honest, high-toned, unselfish, Christian gentleman;
a hater of shams in any form; a good son, husband and father; an
example of devotion to the noblest of professions, and through it a
benefactor of humanity ; our most illustrious Founder, one whom every
student present should strive to emulate.

And now, shade of a most gallant and knightly physician, whose
shield was so often successfully interposed between his intended victims
and the Grim Destroyer — Death, farewell. May the example of your
life shine as a beacon light to lead us on to nobler endeavor, and may
the voice of your teachings long continue to "echo through the cor-
ridors of Time."

I append the following list of his writings :

"Philosophy of Certain Dislocations of the Hip and Shoulder, and their
Reduction." Peninsular Journal of Medicine, Ann Arbor, 1853-4, Volume I,
pages 95-IOO-

Reprinted with some additions in the same journal 1855-6, Volume III,

pages 27-35.
Reprinted in pamphlet form, 1855.
Reprinted with further additions in the Peninsular and Independent

Medical Joumctl, 1859-60, Volume II, pages 193-206.
Reprinted in pamphlet form 1859.
Second edition printed in 1869.
"Selections from Surgical Notes." Medical Independent, Detroit, 1857-8,
Volume III, pages 67, 186, 257, 377, 469, 575-

"Selections from Surgical Notes." Peninsular and Independent Medical
Journal, Detroit, 1858-9, Volume I, pages 464-467; 1859-60, Volume II, pages
140-143.

Doctor Gunn was one of the ^editors of the Monthly Independent, Detroit,
1857-8, Volume III, and of the Peninsular and Independent Medical Journal,
1858-9, Volume I; and 1859-60, Volume II; and was the author of numerous
editorials in these journals, usually signed "G."

"Address of Welcome to Rush Medical College," delivered October i, 1867,
Chicago Medical Journal, 1867, Volume XXIV, pages 499-512.

"Valedictory Address, Rush Medical College," 1870-71. Ibid., 1871, Volume
XXVIII, pages 157-169; also reprinted.

"Surgical Clinic of Rush Medical College." Ibid.. 1874, Volume XXI.
pages 560, 725.

"Discussion of Doctor Gross' Paper on Syphilis." "Transactions American
Medical Association," Philadelphia, 1874. Volume XXV, page 243.

62 ORIGINAL ARTICLES.

"Case of Traumatic Tetanus, Saint Joseph's Hospital." Chicago Medical
Journal and Examiner, 1875, Volume XXXII, pages 421-426.

"Address in Surgery and Anatomy," delivered May 8, 1879. "Transactions
American Medical Association," Philadelphia, 1879, Volume XXX, pages

79-493.

"Report of a Case of Purulent Effusion into Knee-joint." Ibid., 1879, Vol-
ume XXX, page 517-

"Treatment of Fractures of the Skull, Recent and Chronic, with Depres-
sion." Read June i, 1882. "Transactions of the American Surgical Associa-
tion," 1881-83. Philadelphia, 1883, Volume I, pages 83-90.

"The Doctorate Address on Medical Ethics." Chicago Medical Journal and
Examiner, 1883, Volume XLVI, pages 337-352. Also reprinted.

"The Philosophy of Manipulation in the Reduction of the Hip and Shoulder
Dislocations." "Transactions American Surgical Association," (1884) 1885,
Volume II, pages 399-519; also in Chicago Medical Journal and Examiner, 1874,
Volume XLVI II, pages 449-468. Also reprinted.

"The Union of Nerves of Different Function Considered in its Pathological
and Surgical Relations." Address of the President delivered April 28, 1886,
Volume IV, pages 1-13.

BORDERLAND CASES OF INSANITY.*
By IRWIN li. NEFF, M. D.. Pontiac, Michigan.

ASSISTANT PHYSICIAN AT THB KASTBBN MICHIGAN ASYLUM POR THB INSANB.

The subject which I have chosen is not an uninteresting one.
Many cases of questionable insanity have been reported and valuable
information has been obtained. A reference to the literature on this
subject will show a voluminous bibliography. My intention is not to
particularize, but to correlate some of our knowledge on this subject
and isolate a few of its practical aj>plications, — facts which would
appeal to the interest of the general practitioner.

Borderland cases, correctly speaking, would comprise all those cases
in which the alleged irresponsibility of the individual is unproven. As
is well known such a definition would include a number of conditions,
and it is true that many and diverse symptoms accompany such a case.
It is obvious that one considering a "borderland case" must be con-
versant with both normal and abnormal psychology. As it is admitted
that the origin of the moral sense has no fixed period, we see that
a priori we have a task of no little importance.

I would also call attention to the fact that we are in danger of going
to the extreme. On one hand we have the ruling of the criminologists
and students of sociology ; and again we are confronted with the state-
ment of the extremist, who declares that since the degree of respon-
sibility cannot always be defined, everyone should have an equal chance,
and that consequently we should show leniency when occasion demands.
Many attempts have been made to prove or disapprove these statements,
but it must be acknowledged that we have reached no conclusioo which
can give satisfaction.

*Kead at the Ann Arbor meetins^ of the First Councilor District Medical
Society, December 22, 1905.

BORDERLAND CASES OF INSANITY. 63

For a settlement of this perplexing question we naturally turn to the
alienists and criminologists. Let us see what they have to contribute.

Our conception of insanity today is vastly different from our idea
of the psychosis twenty-five years ago, and this is, in great part, owing
to our improved clinical interpretation of mental disorders. Much of
the mystery surrounding practical psychiatry has vanished, ,we hope
forever. A careful study of a number of cases has shown that a
grouping of cases is possible, thereby making the nomenclature of
insanity possible, and simplifying! it to a remarkable degree. We have
also more correct and definite explanatory terms, and have brought
closer together the relationship of the neurosis to the psychosis. And,
lastly, I would call attention to the relationship of bodily conditions and
mental disturbances. Although we believe that in insanity the essential
condition is a disordered action of the brain, we admit that the causes
producing such a disruption may be dependent upon bodily disease or
defect. It is not strange, considering these revelations, that the psy-
chiatrists should demand a more careful study of these cases. They
believe that a more painstaking inquiry into each individual case, along
certain definite lines, would be of material assistance in clearing up
the vexed question of "responsibility."

A review of the writings of alienists on the vexed question of
"responsibility" will show that there is quite a uniform opinion on the
question of its restriction. According to a number of prominent
alienists diminished responsibility is to be charged in cases of even
slight mental affections, in incipient stages of others (as in that of
general j>aralysis), in some psychic degenerations, without delirium,
in borderland cases of insanity, cases of sexual perversion, chronic
alcoholism, neurasthenia, the general epilepsies, and in certain cases
of the other neuroses.

Mercier claims that there is a certain sphere of activity, in which
every insane individual is to be held irresponsible, but outside of which,
any act of his may be punishable by law, so that but a few insane can
be held entirely irresponsible. Mercier inclines to the idea that the
physician should not be permitted, as such, to decide on the degree of
responsibility in these cases, but should simply and clearly describe
the patient's mental state, leaving to the judge the application of the
law (Journal of Nervous and Mental Disease, Volume XXIX, page

739).

The criminologist, proceeding in much the same way a§ the alienist,
has discovered truths which have proven to be of practical importance.
As is well known the relation of crime to insanity has been the nucleus
on which has been built our present knowledge of the criminal. It
has been definitely decided that there is a true relation, — a relation,
which like insanity in some of its respects, is difficult to analyze.

In order to emphasize these statements, and wishing to show con-
certed opinion in regard to the responsibility of the criminal, I give
the following quotation : Doctor W. B. Noyes, writing on the "Crim-

64 ORIGINAL ARTICLES.

inal Equivalent of Insanity," says that "the importance of fixed idea or
obsession on obscure cases in crime cannot be too frequently brought
to the attention of jurists, and the presence of minor eccentricities is
also important, for there is no sharp line to be drawn between the
eccentric and criminal action." Such mental eccentricities, Noyes
believes, are often as clearly stigmata of degeneration as the more
definitely understood physical stigmata. He also speaks of the crim-
inal, who knows both concrete and abstract, but lacks what he calls
"hidden or ethical feeling." "Such a man knows right and wrong,
but will not, on that account, be kept from committing wrong."

The practical application of these facts is possible, but united and
uniform action is called for. It is obvious that there can be no fixed
rule in "borderland cases," but it is nevertheless true that our judg-
ment is called for, and our opinion must be rendered. It is true that
our medical opinions, which should be respected, are often overruled ;
but we should never hesitate to give our verdict, even to the extent of
frankly acknowledging our inability to render more than a conservative
opinion.

The necessity for expert testimony in these borderland cases is
apparent. It i^ unquestionable that medical expert testimony would
be less severely condemned if only the physician familiar with mental
trouble would consent to testify. An alleged case of insanity cannot
be hastily decided upon, for the diagnosis should not be placed on the
existence of a delusion or the presence of some peculiarity, alone. The
diagnosis of mental disease should rather be dependent on the sum of
bodily and mental defects, and the proper correlation of facts gained
by a thorough study of the patient.

Naturally the determination of insanity in a "borderland case"
requires the most exquisite care. The case must be most carefully
considered and extended examinations are often demanded. When
summoned to examine such a case the physician must remember the
character of insanity and appreciate the difficulties which he will
encountei-. The psychiatrist knows that the case requires a most care-
ful handling, and that he, in all probability, will be met with opposition,
which, if he is not experienced, may affect his final decision. One
should also bear in mind that although the practical grouping of the
insanities is now possible, cases are found which cannot be relegated
to any one particular gjoup. Nevertheless such cases are cases of
insanity. The physician should not hesitate to so declare it, giving his
specific reasons and acknowledging his inability to classify it. It must
also not be forgotten that insanity is a protean disease, and it may be
that the peculiarity exhibited by the patient is a prodromal or primary
symptom of a well recognized form of insanity. We should never
arrive hastily at our conclusion, and one must remember that when
undertaking such a case he has set for himself a task which will require
both tact and perseverance.

(i) Insanity is a protean disease. Its syndrome is subject to
variation, and a grouping is not possible in all cases.

CLINICAL SOCIETY. 66

CONCLUSIONS

(2) Borderland cases of insanity are at times more apparent than
real. A consideration of such cases may show that the obscure s)rmp-
tom is really an early manifestation of a psychosis, which can be classi-
fied.

(3) Medical men when testifying in "borderland cases" should
invariably give their reasons for their opinion, and should not, if there
is not sufficient proof, attempt to isolate the symptom and refer it to a
named psychosis.

(4) The degree of responsibility in some of these cases, considering
our present knowledge, cannot be accurately determined. Every case
is a study in itself, and must be determined on its merits.

(5) Expert testimony should be given only by experts. If this
rule was strictly adhered to medical expert testimony would be better
appreciated.

(6) Inability to pass upon a case should be frankly acknowledged.
In cases of doubt, we are justified in giving our testimony, and leaving
the real decision of responsibility to the court and its representatives.

TRANSACTIONS.

CLINICAL SOCIETY OF THE UNIVERSITY OF MICHIGAN.

STATED MEETING, DECEMBER 15, 1905.

The President, ROGER S. MORRIS, M. D., in the Chair.
Reported by DAVID M. KANE, M. D., Secretary.

REPORTS OF CASES.
CARDIAC ANEURYSM,

Doctor George Dock : I wish to describe a case of cardiac aneur-
ysm. The patient was a farmer of fifty-two years, of intemperate hab-
its, and with a scar suggestive of syphilis but denial of history of
infection. From the age of eighteen the patient complained of neuralgic
pain in the pit of the stomach and of pain and tenderness in the heart
region. Two years before death he had a slight paralysis of the right
side, lasting only three hours. For the last four months of life pain in
the heart region was more severe, paroxysmal, and sometimes radiating
down the left arm. Unlike most patients with angina pectoris, the man
became almost maniacal, running around the room, screaming, declar-
ing that the pain would kill him, but without having the oft-described
feeling of impending death. For the last two months the pain in the
heart was almost continuous. There was dyspnea; edema coming on
first in the lower extremities, then becoming general. Physical exam-
ination showed all the evidences of incompensation, the heart dilated

66 ORIGINAL ARTICLES.

and hypertrophied, with a blowing systolic murmur at the apex. The
second aortic was accentuated; the radial arteries tortuous, thick,
slightly uneven; the liver reached to the navel line; urine — specific
gravity 1015, one-fourth bulk albumin, few hyaline casts. For several
weeks he had not been able to sleep. Under the influence of morphine,
diuretin and salt-free diet the patient improved markedly, so that by
the second day of treatment he was able to sleep lying down. In four
days the edema was gone and the heart became smaller. Eight days
after beginning treatment, against positive orders to the contrary and
with a prediction of sudden death in the event, he ate a large meal,
started out for a walk, but after going a block, fell over and was found
to be dead. Autopsy showed adhesions over the front part of the left
ventricle ; the heart enlarged, containing an aneurysm at the end of the
left ventricle, and in the septum, containing a thrombus partly old and
partly recent. There was relative insufficiency of the mitral valve,
slight thickening of aortic flaps, coronary sclerosis, with obliteration of
the anterior coronary in the lower part. The other organs showed con-
gestion, slight atrophy, with moderate parenchymatous and interstitial
changes.

Doctor Dock gave a critical summing-up of the case with reference
to symptomatology, diagnosis, prognosis and treatment. He also called
attention to some of the points of interest in connection with the subject
of sudden death, and gave a detailed account of the history of cardiac
aneurysm from the time of Lancisi. His remarks were illustrated by
a number of old and modem works on heart disease, including Cor-
visart, Laennec, Cruveilhier, Carswell, and also some of the more
important articles in medical periodicals illustrating the development of
our knowledge of cardiac aneurysm.

OVARIAN CYST WITH TWISTED PEDICLE.

Doctor Christopher G. Parnall: Gynecological case number
1408 was admitted to the University Hospital on September 21, 1905.
Age forty-two ; married nineteen years.

Family History. — Negative.

Personal History. — Had all the ordinary diseases of childhood with
good recoveries. For many years she has had attacks of headache.
Patient says she has never been real well.

Menstrual History. — Menses appeared at age of twelve. Last period
seven weeks before admission. Very irregular, one to two months.
Duration, one to two days. Amount scanty, one or two napkins for
whole epoch. No pain. Moderate vaginal discharge.

Marital History. — No children. No history of abdrtions.

Present Trouble. — It began about three years ago with pain in both
groins, worse on left side. The abdomen increased in size very slowly.
The enlargement seemed to be general and not confined, even at first,
to either side. At the last menstrual period there was severe pain in
the lower abdomen beginning on the right side and extending to the

CLINICAL SOCIETY 67

left There is a history of a number of attacks similar to the above
except that the pain was not so severe. No nausea nor vomiting.
Patient does not think she had ferer.

Examination, — There is a great development of adipose tissue,
patient weighing two hundred and thirty pounds. Otherwise the gen-
eral examination is negative. There is a marked abdominal enlarge-
ment extending from the pubes upwards to the epigastrium. This
swelling is dome-shaped. Lineae albicantes marked. There is a deep
suprapubic transverse furrow, above which the tumor is dome-shaped,
smooth and symmetrical. It is sensitive and somewhat movable. Per-
cussion note is dull over the tumor, tympanitic in the flanks. No fluid
wave. Vaginal examination shows the uterus retroverted. Append-
ages not palpable. Nothing can be made out in the fomices of the
vagina.

On the day after admission the examination of the urine revealed
a positive test for sugar. On a so-called carbohydrate-free diet the
sugar disappeared. The patient was kept on diabetic diet for a week
preceding operation, during which time there was no reappearance of
the glycosuria.

Diagnosis. — Ovarian cyst. On account of the sensitiveness and
history of sudden attacks of pain, it was thought probable that a twist
of the pedicle would be found, possibly with adhesions of the cyst wall
to the surrounding peritoneum, and infection of the contents.

Operation. — On September 25, 1905, by Doctor Peterson. The
abdcHnen was opened by an incision thirteen centimeters long, in the
median line. The subcutaneous fat was six and one-half centimeters
in thickness. On opening the peritoneum it was found that the cyst
wall was adherent to it for a radius of about ten centimeters. The
adhesions were thin and vascular. They were loosened by sweeping
the hand between the cyst wall and the peritoneum. About nine liters
of muddy-colored fluid were removed by the trocar. The cyst was then
easily removed by clamping the pedicle, which was twisted counter-
clockwise for half a turn. The left ovary was enlarged and cystic and
was removed. The uterus was held forward by ventro-suspension.
Four days after operation sugar again was found in the urine and did
not entirely disappear under diabetic diet. The wound healed satis-
factorily and convalescence was uninterrupted.

This case is of interest from the standpoint of diagnosis. Twist
of the pedicle of an ovarian cyst is not uncommon, still the condition
often goes unrecognized.

The torsion may be acute, resulting in severe sudden symptoms, or
chronic, with less marked changes. In the first variety there is a
sudden cutting off of the blood supply, particularly on the venous side,
and hemorrhage into the cyst. Acute torsion may resemble in many
ways the rupture of an ectopic gestation sac. There is usually sudden
severe pain coming on after exertion, movements of the bowels, or
urination. The patient may faint and present signs of internal hem-
orrhage.

68 ORIGINAL ARTICLES.

In the chronic form the torsion is slow, the circulation in the tumor
is interfered with only gradually, and adhesions often form between
the cyst wall and the neighboring V^lvic organs or the parietal peri-
toneum. The cyst may thus obtain a large share of its blood supply
through these adhesions.

The temperature is usually not much elevated, generally ioo° to
102° Fahrenheit. The pulse in acute torsion is frequently very rapid,
ranging from 100 to 160 per minute. When there is a marked
adhesive peritonitis vomiting is a prominent symptom. Intestinal
obstruction may occur as a result of the inflammatory changes involv-
ing the cyst and intestines or frcxn pressure of the tumor. Palpation
in uncomplicated cases of ovarion cyst is accomplished without causing
even discomfort. In case of adhesions involving the Serous mem-
branes there is abdominal rigidity and marked sensitiveness. A small
right-sided adherent cyst may indeed be easily mistaken for appen-
dicitis or periappendical inflammation.

A CASE OF ACUTE CHOREA.

Doctor Theophil Klingmann: All the facts which have been
gathered by the pathological anatomist and the physiological chemist
in the study of chorea offer no explanation of the defects that give rise
to the condition. No constant lesions have been found. Although
certain organic changes are often associated with the disease, it is not
infrequent to observe cases that are truly functional and give support
to the view that chorea is an expression of functional instability of
those nerve centers which have assigned to them the office of con-
trolling the motor apparatus. Of the actual nature of this derange-
ment we know little or nothing; whether the fault is primarily in the
cortical cells or whether the impulses are secondarily disturbed in
their course down the motor path. Hereditary influence is discover-
able in many cases of chorea. A neuropathic heredity has been found
in one-sixth of the cases. Frequently a double relationship of the dis-
ease can be traced to acute rheumatism on the one hand and to various
nervous disorders on the other.

The case in question, a patient of good general appearance, twenty-
four years of age, gives evidence of hereditary influence. The father
of the patient has had rheumatism. We must not, however, lay too
much stress upon this fact, as rheumatism is so common that it is only
significant when the family tendency is very strong, or when the sub-
ject has endured much suffering from the disease. The mother of the
patient died at the age of thirty-six, of pulmonary tuberculosis. One
sister died of the same disease at the age of thirty. Another sister
had chorea for several months at the age of fourteen, but recovered
completely. The patient's health was good until her eighteenth year,
when she became somewhat nervous and fretful and complained of
forgetfulness. She recovered from this condition without treatment,
however, and was quite as well as ever until the present affection began.
She experienced her first attack of chorea three years ago, when she

CLINICAL SOCIETY. 09

was twenty-two years of age and four months past her third confine-
ment. Her first pregnancy terminated prematurely at seven months;
the second four years ago at full term; the third and fourth preg-
nancies also being at regular time. The nervous condition at first
manifested itself in severe headaches and marked irritability, which
was followed by involuntary muscular movement in the face, the tongue,
and later in the upper and lower extremeties. This continued for about
two months and ended in complete recovery. One year later she had
a second attack. This siege was much less severe and lasted but a
short time. She became pregnant soon after this attack and remained
well until five months after confinement, when a third, the most severe
attack, developed.

The patient came to the University Hospital in November, 1905.
She had suffered frc«n chorea since August without intermission.
While her general appearance is fairly good she has lost about thirty
pounds since the beginning of this attack. There is no apparent cause
for this loss of weight except continual worry and anxiety together
with annoyance incident to constant involuntary muscular contractions.
Her sleep is very much disturbed. There is no disturbance of diges-
tion. The appetite is good. The patient is not anemic. In fact there
is no evidence of organic disease in any organ except the heart, and
the lesion indicated gives the patient no discomfort. There is con-
siderable muscular weakness present. The spontaneous movements
and incoordination are most marked in the arms and hands, but the
face, and, to some extent, the lower extremities, were likewise affected.
The movements are very irregular as to time as well as in character
and degree. Sensibility is not disturbed and there is no pain or
tenderness in any part of the body. The mental state is normal.
The cardiac symptoms, which are the only evidence of organic disease
in the case, are of great importance. The frequency of organic disease
of the heart is less in childhood than in youth. In chorea, developing
late, as it did in this patient, the cardiac symptoms are usually those
of organic disease and frequently mitral regurgitation. It is reported
that in nine out of every ten fatal cases the cardiac valves are diseased.
Statistics in the various clinics show that distinct organic disease
either preceding or developing during the course of chorea was found
in thirty-two per cent of the cases. What part this plays as a causative
factor cannot, with our present knowledge of the disorder, be ascer-
tained. The changes which have been found after death afford no
clear indication that the circulation is primarily deranged. In the
majority of cases of the common form of chorea the heart lesion gives
the patient little or no discomfort, even though it persists after the
involuntary muscular movement has entirely ceased. The same is true
of other pathologic conditions occurring before or during the course
of the disease. It seems more likely that one common cause disturbs
the functions of the various organs of the body, as well as the functions
of the nerve centers in the brain. This cause may possibly be found
in some toxin which accumulates in the organism. This is borne out

70 ORIGINAL ARTICLES.

by the fact that treatment directed to improve elimination through the
bowels, kidneys, and skin will relieve the symptoms greatly. Further
evidence is given by the fact that the conditions with which chorea is so
frequently associated are caused by autointoxication. We must not
lose sight of other etiologic factors in the treatment of this disease.
There is a distinct predisposing influence of much importance. Chorea
occurs most frequently during later childhood when the functional
develojMnent of the nerve centers has been effected, but the exercise
thereof has not yet secured stability of function, leaving them very
susceptible to outside influences. The normal restlessness of childhood
manifests the predisposition to chorea. With this predisposition is to
be associated the important fact that emotion has been frequently the
exciting cause. In the case under consideration the condition devel-
oped rather late, but at a time when considerable strain was brought
to bear upon an unstable nervous system by the responsibility of a child
and other household duties, not to forget the untoward effects of a
premature labor.

When the patient came to the hospital it was markedly evident that
both nutritk>n and elimination were defective. The first attention,
therefore, was given to these pathologic states. The patient was put to
bed and kept at rest. Oiloral hydrate was adijainistered in ten-grain
doses every three or four hours to the extent of controlling the involun-
tary muscular movements, and in addition five to ten drops of Fowler's
solution were given three times a day. At present the patient is ahnost
well. The choreic movements are slightly noticeable in the hands, but
otherwise have entirely disappeared. Under this treatment the duration
of the disorder is usually short and the prc^^osis extremely favorable.

CLINICAL SOCIETY OF THE NEW YORK POLYCLINIC.

STATED MEETING, JANUARY 8, 1906.

The President, JOHN J. MacPHEE, M. D., in the Chair.
Reported by FREDERICK C. KELLER, M. D., Secretary.

READING OF PAPERS.
THE TREATMENT OF SYPHILIS,

Doctor Andrew R. Robinson read a paper on this subject. He
referred to the different views held on the subject of the treatment of
syphilis, and stated that he would endeavor to show that syphilis is a
serious disease in a considerable percentage of cases, and especially on
account of the tendency after immunity is reached to fatal parasyphilitic
affections; that the tendency to these parasyphilides depends as a
special predisposing factor upon the dyscrasic condition accruing in the
active contagion stage; that the intoxication producing the dyscrasia
and leading to immunity often is most severe in the period between the
recognition of the primary sore and the appearance of lesions upon the

CLINICAL SOCIETY. 71

cutaneous surface, and, therefore, that syphilis should be treated actively
as soon as a positive diagnosis of the disease is made.

The object of such treatment is to inhibit the life action of the
organism, so that only a small amount, comparatively, of toxin is pro-
duced, giving immunity with only a mild dyscrasia, and producing a
minimum amount of injury to the tissues and consequently a compara-
tively slight tendency to parasyphilides or even tertiary lesions. He
maintained, also, that in the acute infectious stage it is a rule that the
less toxin produced in a given case, the earlier the system acquires the
condition of immunity ; and in syphilis this is important not only for
the individual affected, but also from a social standpoint, as the sooner
immunity is obtained the less danger of contagion to others.

An example of early immunity is that acquired by a mother in a
case of parental syphilis, when she is not invaded by the syphilitic
organisms, but acquires immunity by toxins from the fetus. Under
these circumstances the amount of toxins passing to the mother must
be small in quantity and therefore the immune condition is acquired in
a comparatively short period as compared with the time necessary in
acquired syphilis.

Syphilis is a serious disease, not only on account of the liability to
fatal parasyphilitic affections, as locomotor ataxia, but also on account
of its destructive action on the progeny of syphilitic parents when pro-
duced during the active stage of the disease, hence the shorter this
period exists the fewer syphilitic children are produced.

If the tertiary parasyphilides depend very greatly or principally
upon the severity of the dyscrasia, and this condition upon the amount
of intoxication, that is, the amount of toxins produced, and this upon
the number and activity of the syphilitic organisms in the system, it
follows that in this special parasitic affection the treatment of syphilis
must be based upon the microbes, the toxins produced, and the ground
of the individual affection. Proper consideration of these three points
constitutes the fundamental basis for the best treatment of the disease.

Syphilis is a continuous condition from the time of infection until
the last microbe is gone ; hence the division of the disease into stages is
not scientifically correct, although for clinical description it is of some
value.

In the period between the appearance of the primary sore and the
so-called secondary stage, represented by cutaneous lesions, the general
nutrition of the person is lowered, fever is present in varying degree,
the red-blood corpuscles are diminished in number, the lymph glands
throughout the body may be affected, the spleen swollen and tender,
I liver enlarged and the nervous system injured, as shown by the pres-

ence of neuralgia, headache, lassitude, pains in the joints, bones, and
j periosteum, and occasionally by an extensive multiform erythematous

eruption. This shows that before secondary lesions occur upon the
skin there may be intoxication of the general system, which leaves its
impress on the tissues and acts as the main disposing factor in the

72 ORIGINAL ARTICLES.

^causation of parasyphilides. If this be true, it follows that treatment
should be commenced in every case as soon as a positive diagnosis is
made, and if this is done at a stage before cutaneous lesions appear,
so much the better for the patient.

Existing lesions in the secondary stage are treated to lessen danger
of contagion, remove deformity and save tissue, but surely it is better,
more philosophical, to prevent the formation of lesions, especially as
they are hotbeds for toxin formations, than to wait until they are
formed and damage has occurred. The treatment of syphilis should
be offensive, not defensive. Keep the disease in as quiescent a state as
possible by inhibiting the life action of the organism ; prevent contagion
from lesion formation ; promote the elimination of the toxins as quickly
and completely as possible, and pay attention to the general nutrition
of the patient. This constitutes the correct treatment of syphilis accord-
ing to our present knowledge.

Mercury is the only agent that acts upon the microbe, hence it
should be given during the entire microbic stage in such manner as to
secure the best action. lodid of potassium should be given only as an
aid to the mercury or as an alternative in later stages and at all times
when tertiary lesions are present. It is rarely indicated during the first
six months of the disease, and never during the microbic stage, as the
only agent.

Against the parasyphilides one should produce a proper degree of
alkalinity of the system, advise avoidance of everything that causes
circulatory disturbances and of things that interfere with tissue metab-
olism, especially alcohol, local irritating agents, et cetera.

DISCUSSION.

Doctor Edward L. Keyes, Jr. : While I agree with all the conclu-
sions reached by the author, I disagree wholly with all the premises.
Briefly, in his opinion, the way to treat syphilis is as a disease and not
as an array of symptoms. The most practical method is to settle in
one's mind the amount of medicine considered necessary in all cases to
overcome the disease. One grain of iodide of mercury every day for
three years will conquer it, and even though the skin lesions have disap-
peared, together with the mucous patches in the throat and all other
outward manifestations, the physician should still try to live up to his
ideal of the amount of mercury or iodid that should be taken by the
patient, whether he stands it well or not. I disagree absolutely with the
speaker regarding the method of treatment at the beginning of syphilis.
It is extremely dangerous to proclaim that syphilis should be treated
before the appearance of a cutaneous lesion, because, in a very fair pro-
portion of cases, one is unable to make a positive diagnosis until the
appearance of the secondary lesions. Theoretically, if it is proved that
the existence of the spirocheta pallida is conclusive of syphilis, treat-
ment may begin as soon as it is recognized, but until this is possible,
it is wiser to wait for secondary evidence. I recall two instances in

CLINICAL SOCIETY. 73

which patients who presented themselves for treatment within twelve
hours of the supposed inoculation had developed a chancre six weeks
later.

Doctor Charles H. Chetwood : There seems to be a general ten-
dency at the present time to question whether syphilis should be treated
in the primary or in the secondary stage. The reader of the paper has
emphasized the point that the question is not when to treat it, but that
it should be treated when the diagnosis has been made. For my part,
I have always treated it when the secondary eruption appeared, and
consider it a safe procedure. I would not advise commencing treatment
earlier unless the presence of the disease should be positively substan-
tiated by the spirocheta pallida or some other germ. I treat all cases
according to the general exigencies of each individual condition, and
the results have been most satisfactory.

Doctor Joseph H. Abraham : Next to the dermatologist and the
genitourinary surgeon, the nose and throat specialist sees as many cases
of syphilis as any of the specialists. They rarely see any primary syph-
ilis, but many secondary and tertiary cases come to their notice. Per-
sonally, I have seen five cases. One patient had the initial lesion on the
lip and the other four on the tonsils, and in one case the upper respira-
tory glands showed marked symptoms of intoxication. Another marked
feature is the enlargement of the leutic glands. I agree with the prin-
ciples laid down by the reader of the paper for the treatment of primary
syphilis. Secondary syphilis of the larynx should be treated entirely
by personal rule. I rely upon one drug, carbolic acid. An application
of ten per cent chromic acid to the larynx gives rise to practically no
pain and accomplishes the desired result. If the patient is given a
sufficient amount of mercury for a long enough period of time, he is
less liable to require the iodides or to suffer from a marked tertiary
form later. I have never found it necessary to give more than seventy-
five or eighty grains of the iodid at one dose, and always begin with
five grains and increase one grain daily or every other day. The absorp-
tion occurs as desired and the digestive tract is not disturbed.

Doctor Robert H. M. Dawbarn : I believe the wisest course is to
begin treatment of syphilis as soon as one is sure of the character of
the lesion. I do not agree with the statement that the iodid of potas-
sium has no direct bearing upon the foundation of syphilis. In my
opinion, overeating and overdrinking may so change the metabolism of
the hunian system as to render the effects of syphilis more intoxicating.

Doctor John A. Bodine: The time to begin treatment depends
greatly on the character of the patient. The primary duty of the phy-
sician is to effect a cure. If the patient is a highly intelligent one, the
treatment may begin as soon as the diagnosis is positively made, as
that character of patient may be depended upon to carry the treatment
through to its logical conclusion. With a more ignorant patient, it is
often necessary to first convince him that he is a victim of this disease
in order to impress upon him the necessity for systematic and long-

74 ORIGINAL ARTICLES

continued treatment and in this case the appearance of the skin erup-
tion following the sore convinces him that he has syphilis.

Doctor Robinson : I still think the treatment should be begun, if
possible, during the first stage of the disease. If the patient presents
what he considers the initial lesion, I recommend a six weeks' course
of treatment with mercury, and if, at the end of that time, there remains
any question as to the diagnosis, it is very easy to bring out a small
lesion as convincing proof.

REPORTS OF CASES.
URETHRAL FISTULA AND PROLAPSED KIDNEYS,

Doctor Charles H. Chetwood: I wish to show a patient on whom
I operated two years ago for urethritis, and who at the present time
has an incomplete fistula. When first examined his symptoms seemed
to point toward the urethra and prostate, the latter being about the size
of a small orange and very hard. The history indicated a gonorrheal
infection, and, apparently, a syphilitic abscess of the prostate. The
patient urinates every half hour, day and night, and the bladder con-
tains about twelve ounces of residual urine. The appearance of the
urine is indicative of kidney pus. Both kidneys are prolapsed and the
right one is very palpable, enlarged and tender. The interesting feature
of the case is the prolapse of both kidneys without any apparent explan-
ation. There is no tuberculous history and none suggestive of kidney
disease. My intention is to drain the prostatic abscess through a per-
ineal incision, examine the bladder through the opening, and possibly
catheterize one of the ureters.

SYRINGOMYELIA OR LEPROSY f
Doctor John A. Bodine: I desire to present this patient. She is
twenty-one years of age, and her family history is negative. About six
years ago she first noticed that she was unable to distinguish the impact
of the soles of her feet against the sidewalk and began to have aching
pains in her feet and legs. Later, pus formed beneath callous spots on
the feet and discharged, leaving sinuses leading down to the metatarsal
bones. Rest in bed healed the sinuses, but on resumption of her occupa-
tion they reopened. Pain was present in her spine from the neck to
the coccyx. She was operated on for contractures of the feet in 1902.
Her general health is now fair. The soles of her feet are covered with
multiple perforating ulcers. The discharge is thick, brownish in color,
and has a peculiar sickening, penetrating odor. There is an abscess
under the skin in one thigh and another over the sacrum. There are
marked motor and sensory disturbances of the feet and legs. The case
is presented for diagnosis, which I think lays between syringomyelia

and leprosy.

discussion.

Doctor William B. Pritchard : I consider this patient an example
of syringomyelia presenting the exception in a distribution of symptoms
in the lower rather than the upper extremities, though both are involved.

The trophic disturbances in the feet, with bladder symptoms, scoli-

MALTA FEVER. 76

osis, and, finally, dissociation sensory phenomena, indicate with fair
clearness the diagnosis. It is not a leprous neuritis, as the nerves show
no bulbous enlargements and the skin is quite free from the characteris-
tic plaques. Tabes has been suggested, but there is little in the symptom
picture to sustain such a suggestion. Absence of the Argyll-Robertson
pupil, the persistence of one knee-jerk, with absence of true ataxic gait
and characteristic pains were collectively conclusive in negation.

ORIGINAL ABSTRACTS.

MEDICINE.

By GEORGE DOCK, A. M., M. D., D. Sc, Ann Arbor, Michigan.

PltOFBSSOII OF MBOBCim IM TMB VMIVmMTT 09 MICHIGAM.
AND

DAVID MURRAY COWIE, M. D., Ann Arbor, Michigan.

riR^T ASSISTANT IN UBOICINB IN TMS VNIVUISITV OW MICMIOAN.

MALTA FEVER.
Charles F. Craig ("International Clinics," Volume IV, Fifteenth
Series, page 89) gives a brief but very valuable study of this interesting
disease, based upon twelve cases observed by himself. One of the
twelve seems to have acquired the disease in Washington, District of
Columbia, the first recorded as originating in the United States. None
were fatal ; all but one had had one or more previous attacks ; seven pre-
sented acute exacerbations, five, chronic symptoms. Craig finds the
symptomatology so complex that no case can be considered as abso-
lutely typical. The most marked symptom and the one most complained
of is severe pain in the muscles and around the joints. In acute
cases it was most intense in the lumbar regions and the extremities. In
chronic cases it was generally localized around one or more joints, was
paroxysmal, often leaving one joint and appearing in another. The
temperature curve is not so characteristic as has been believed. In first
attacks the undulant type occurs, with a gradual rise, gradual fall, and
several days of normal temperature. But even in acute cases such tem-
perature curves are the exception. "In the majority of cases . . .
the temperature curve, instead of being an aid to diagnosis is the
reverse, and is the chief cause of mistaken diagnosis." There is an
anemia, with leucocytosis, the white count ranging from 16,000 to as
high as 28,000, the increase being in the polynuclears. The kidneys
seem to escape injury ; even albuminuria is rare. Pain and swelling of
the joints do not usually occur in first attacks, but during the second,
third or fourth; rarely not at all. There is moderate swelling, with
some reddening of the skin. The skin is hot ; there is great tenderness
on pressure, but no effusion can be detected. The most valuable aid to
diagnosis is the agglutination test with micrococcus melitensis, first
observed by Wright, of Netley, and in high dilutions — preferably i 75.

76 ORIGINAL ABSTRACTS.

The reaction is marked and immediate. Craig has never found the
reaction in any other disease ; it failed him once in an undoubted case.
Malaria, typhoid fever, tuberculosis, pneumonia, septicaemia and
pyaemia, relapsing fever, and Hodgkin's disease and articular rheuma-
tism must be differential. The author suggests a wider distribution
for Malta fever, even in temperate latitudes, than is generally supposed.

OLD.

SURGERY.

By frank BANGHART WALKER, Ph. B., M. D., Detroit. Michigan.

ntOVBaOOII op SUWLGWMX and OPBRATIVB SUHCBftT IN THE OBTKOIT POSTGRADUATB SCHOOL OP UBDICINB.'
ADJUNCT PKOPBSSOR OP OPBKATIVB 9URGBRY IN THB DBTROIT COLLBGB OP MBDICINB.

AND

CYRENUS GARRITT DARLING. M. D, Ann Arbor. Michigan.

CUNICAL PROPBSSOR OP 9URGBRT EN THB UNIYRRSITY OP MICHIGAN.

SCOPOLAMINE AS AN ANESTHETIC AID.

Without championing any anesthetic or mode of anesthesia,
Royster sums up in Surgery, Gynecology, and Obstetrics for February,
1906, his experience with fifty cases. He believes : ( i ) That ether is
our safest general anesthetic; (2) That ethyl chloride secures the pleas-
antest primary narcosis; and (3) That the preliminary use of scopola-
mine with morphine increases the patient's mental resisting power and
lessens the quantity of ether.

From its use clinically the writer does not regard scopolamine iden-
tical with hyocine. He believes it safe in proper doses, not to exceed
one one-hundredth of a grain. This dose he has sought to use with
one-sixteenth grain of morphia about one hour before the time set for
the operation. When the patient is brought in, primary anesthesia is
induced in about one minute by ethyl chloride sprayed 6n several layers
of gauze folded over nose and mouth. The ether cone is then used and
the patient is- ready in four or five minutes. This method, appar-
ently complicated, he states is really simple and produces sleep safely,
swiftly, and sweetly. He does not regard scopolamine harmless, how-
ever, two cases having caused his anesthetizer to doubt whether he
should proceed. f. b. w.

GYNECOLOGY.

By REUBEN PETERSON, A. B.. M. D., Ann Arbor, Michigan.

PltOPBSSOK OP GTNBCOLOGT AND OB8TBTKXCS IN THB UNIVBIISITY OP MICHIGAN.

AND

CHRISTOPHER GREGG PARNALL, A. B., M. D.. Ann Arbor. Michigan.

PIRST ASSISTANT IN GTNBCOLOGT AND OBSTBTRICS IN THB UNIVBRSITT OP MICHIGAN.

THE TREATMENT OF ABORTION.

BoLDT (Journal of the American Medical Association, Volume

XLVI, Number H) considers at length the treatment of abortion in its

various stages. He divides abortion into four classes, that is: (i)

Imminent abortion, in which the symptoms may subside on treatment;

ORIGIN OF TUBERCULOSIS IN CHILDREN. 77

(2) Progressing abortion, when the expulsion of the ovum cannot be
prevented; (3) Incomplete abortion, when the contents of the uterus
are partially expelled, some portion still being retained; (4) Complete
abortion.

The treatment of imminent abortion consists in absolute rest in bed
and the administration of morphine or codeine as necessary. Tampons,
ergot, and ice-bags are to be avoided on account of the liability of start-
ing up uterine contractions.

Progressing and incomplete abortion, in the absence of symptoms

of sepsis, are to be treated by first giving a hot antiseptic vaginal douche

[ and then firmly packing the vagina with gauze. After twenty-four

j hours the gauze is removed and usually the products of conception are

! found free in the vagina. In case the os is well dilated and the ovum

still remains in the uterus it may be possible to introduce the finger

and effect a manual removal, or the vaginal packing failing, the cervix

and lower uterine segment may be tamponed and the vagina filled with

gauze; the subsequent procedures being the same as after vaginal

packing alone. Should the bleeding be severe when the patient is first

seen, it is inadvisable to adapt the above plan. Instead, the cervical

canal should be dilated sufficiently if not already patulous and the

ovaum or retained decidua removed by the finger or with a placenta

forceps. Ergot may then be given.

Complete abortion requires no treatment except rest in bed, vulvar
irrigation, and the usual measures carried out with puerperal cases.
Curetment to remove the decidua is unnecessary and hence inadvisable.

If there is bleeding several weeks after a supposed abortion the
uterine cavity should be examined and, if necessary, curetted. When
evidences of infection are present, the uterine cavity should be emptied
as completely as possible, whether the ovum has been spontaneously
expelled or not. A curet should be used to remove adherent infected
membranes or decidua, and an antiseptic intrauterine douche carefully
given. Great caution is always necessary in curetting the uterus after
an abortion.

The general tenor of the article is in advocacy of a conservative,
expectant method of treatment in all noninfected cases of abortion.
The author is of the opinion that much harm has come from a tendency
on the part of many practitioners to adopt really dangerous methods of
interference in simple cases. c. g. p.

PEDIATRICS.

By ARTHUR DAVID HOLMES, M. D..C. M., Detroit, Michigan.

ORIGIN OF TUBERCULOSIS IN CHILDREN.

Hynds (Virginia Medical Semi-Monthly, May, 1905) observes that

tuberculosis in children is a more frequent occurrence than is commonly

supposed. Fisher says that one-third of the deaths of childhood are

due to tuberculosis in some form or another, and more frequent under

78 ORIGINAL ABSTRACTS.

the age of four years. The bones, joints and lymph glands are the parts
most frequently affected. Its great prevalence in children during the
milk-drinking age and the predominance of other types than the pulmon-
ary would seem to indicate a bovine origin and in communities where
the milk was Pasteurized the percentage of intestinal forms was less
than in districts where the milk was fed raw. The British Commission
found that the tuberculosis produced in cattle by material from human
and bovine sources was identical in its general effect and in detail.
Walbach and Ernst came to the conclusion that there was no difference
in the specificity between tuberculin made from human and bovine
bacilli and that there was no essential difference in the disease processes
caused by bacilli from these sources. Rau believes that primary intes-
tinal tuberculosis and tabes mesenterica are of bovine origin and
conveyed by milk. Woodhead believes the same. Still thinks that
tuberculosis of the intestines is often secondary, caused by the swallow-
ing of the sputtUTi. Behring says "The milk fed to infants is the chief
cause of consumption." The evidence as to the communicability of
bovine tuberculosis to infants is so conclusive that there is no longer
any room for doubt. The only point in question is as to the comparative
frequency of this mode of infection. This source of infection is
no doubt very frequent. It is our duty to guard against tubercular
infection in every possible way and to insist on milk absolutely free
from tubercle bacilli for infant feeding. The cows should be tested
with tuberculin and those which react positively should be separated
from the herd.

ORTHOPEDICS.

By IRA DEAN LOREE, M.D., Ann Arbor, Michigan.

FIRST ASSISTANT IN 8URGBRT IN THE UNIVBRSITT OF MICHIGAN.

SOME DEFORMITIES ANQ THEIR PREVENTION.

David T. Bowden, M. D., in the International Journal of Surgery
for February, 1906. Under this heading he describes some of the more
common congenital deformities of the lower limbs, their causes, and
treatment; also some of the acquired forms of deformity, in different
parts of the body.

The valuable part of the article must be summed up in the para-
graphs devoted to the responsibility in neglected cases. The family
physician as well as the parents must be educated to know the value
of early intervention in all cases of deformity, especially those of
congenital origin. Much can be gained even in those cases that reach
the orthopedic surgeon late, yet complete obliteration of the marks of
neglect is often impossible. The surgeon must be given the best
chance and this necessitates early supervision of the treatment. The
inconvenience and mental suffering of these patients should be im-
pressed upon the parents' and the family physician should be in a
position to detect these abnormalities at once.

INJURIES OF THE EYE. 79

OPHTHALMOLOGY.

By WALTER ROBERT PARKER. B. S., M. D.

rROFBSSOR OP OPHTHALMOLOOT IM TRB UlflVBSSITY OP MICHIGAM.

INJURIES OF THE EYE FOLLOWING PARAFFIN INJEC-
TIONS IN THE NOSE.

Professor W. Uhthoff, of Breslau (Berliner Klinische Wachen-
schrift, December, 1905), gives the following reports concerning fre-
quently practiced injections of paraffin in the nose.

A married woman, aged forty-five, exhibited saddle-nose. While
there was a history of traumatism, examination rendered a specific
origin not improbable. There was a history of rheumatism. The heart
was normal. In all there had been three injections of paraffin, at inter-
vals of eight and five months, for the treatment of the nose deformity.
During the third injection the patient suddenly noticed the left eye
becoming blind. There was no pain, but some lachrymation and sev-
eral attacks of vertigo were experienced on her way home. There were
no material inflammatory manifestations, but there was, however, on
the day following the injection, an ophthalmoscopic picture of embolism
of the central retinal artery. Vision mV. The diagnosis was confirmed
eight days later. A puncture on the left side of the anterior chamber,
followed by massage of the globe, did not change the findings of the
examination.

Doctor Uhthoff thinks there is no doubt that a small particle of par-
affin was the real obstacle that beclouded the arteria centralis retinae,
ind it must be assumed that the foreign body passed through the pul-
monary circulation prior to entering the artery. Cases of this kind
must be regarded as exceedingly rare occurrences.

An analogous case is that reported by Hurd and Ward Holden ("A
Case of Blindness Following a Paraffin Injection Into the Nose," New
York Medical Record, July 11, 1903), in which, after the third injec-
tion, loss of vision likewise occurred in the corresponding eye under
the picture of embolism of the central retinal artery. In explanation of
this case Hurd and Holden are inclined to presuppose a persistent fora-
men ovale between the two atria, enabling the particle to pass from
the right atrium into the left, thus obtaining direct access to the arterial
circulation.

This assumption seems to Uhthoff somewhat arbitrary, and he does
not claim the same for his case. The most probable explanation, accord-
ing to the writer, is that in this case paraffin found its way during injec-
tion into the venous system and after passing through the pulmonary
circulation entered the arterial system and consequently also that par-
ticular arteria centralis retince,

A similar case was reported by Moll {Ann. des Mai, d'Orielle du
Lar, et du Phar,, 1902), also one by Rohmer (Ann. d'Occuliste, 1905).

In Leiser's case, which was reported in the Deutsche medicinische

80 ORIGINAL ABSTRACTS.

IVochenschrift, January, 1902, amaurosis of the left eye occurred after
the third paraffin injection, there being initial collapse and continuous
vomiting, followed by inflammatory turgescence of the palpebrae, les-
sening of motility, and symptoms of interocular hemorrhage. Leiser
here assumes the development of a thrombosis of the vena ophthalmica.

After speaking of the dangers of liquid paraffin as compared with
semifluid, and mentioning the means of prevention of embolism sug-
gested by Leiser, the author reports his second case.

A male, aged fifty-seven, was kicked in the face by a horse, with
the resultant deformity of saddle-nose. Three paraffin injections were
made in 1904, and the result was satisfactory until the end of February,
1905. About that time, on a rather warm day, patient had exerted him-
self to the extent of profuse perspiration. Suddenly he felt an itching
and pressure in both eyes which he proceeded to rub. In the course
of a few hours they became swollen, and lids and face inflamed. On the
following day he was unable to open his eyes. Microscopic examina-
tion of a small piece of skin excised from the strongly swollen palpebrae
proved that the inflammatory proliferation was caused by penetration
of the paraffin into the eyelids. For several months patient was
unable to open his eyes. In order to enable him to open his lids
at least to some slight extent and to use his eyes, it was necessary to
remove the hard, tumor-like proliferation of the lids. Microscopic
examination was in harmony with the clinical findings. The inflam-
matory proliferations are occasionally not sharply circumscribed but
coalesce diffusely into the surrounding tissue. Consequently these are
not sharply circumscribed and encapsulated paraffin tumors, but infil-
trations of the tissue with paraffin particles and strong interstitial
inflammatory proliferation. In fact at this time large quantities of par-
affin in substance are no longer demonstrable in the newly-formed
tissue, but the exceedingly numerous giant cells of foreign bodies indi-
cate that diflFuse paraffin particles in the tissue have decided the point
of origination for the new formation of the strong inflammatory tissue.

OTOLOGY.

By R. bishop CANFIELD, A. B.. M. D.. Ann Arbor. Michigan.

PROPBSSOR OP OTOLARYNGOXX>GY IN THB UNIVERSITY OP MICHIGAN.
AND

WILLIAM ROBINSON LYMAN, A. B., M. D., Ann Arbor, Michigan.

DBMOMSTRATOR OP OTOLARYNGOLOGY IN THB UNIVBRSITY OP MICHIGAN.

ACUTE BILATERAL MIDDLE EAR SUPPURATION FOL-
LOWING AN INTRANASAL OPERATION, AND
RESULTING IN DEATH FROM PYEMIA.
Otto J. Stein, M. D., in The Laryngoscope, Volume XVI, Number
I. The salient points in this case are:

( I ) An acute suppurative process in both ears, following an intra-
nasal operation.

MIDDLE EAR SUPPURATION. 81

I (2) Absence of all pain or tenderness in or about the ears subse-

j quent to the incision of the drum membranes on the third and fifth days

j respectively.

j (3) A profuse aural discharge, showing only diplococci, continu-

ing for sixteen days.

(4) A most profound deafness.

(5) The maintenance of a high temperature for sixteen days, with
no decided changes excepting one complete remission on the seven-
teenth day.

(6) Absence of rigors and perspiration.
^ (7) Pus in the urine.

(8) Diarrhea.

(9) Metastasis in the knee-joint and side of the thorax.

( 10) A complicating angina of the soft palate and arches, with the
membrane showing diplococci catarrhalis infection, the same as found
in the ears.

The patient was a female, forty-one years old, thin and weak, but
complaining of no particular ailment. Two days after removal of the
posterior end of the left inferior turbinate she suffered from earache on
the right side. The membrane was incised on the third day. On the
fourth day the left ear ached and the membrane was incised. After the
incisions all pain disappeared and both ears discharged freely. The
temperature from the first remained high with no remissions. Doctor
Stein saw the case on the thirteenth day of the first ear symptoms, at
which time the temperature was 102**, pulse 120, regular and full, res-
piration 28. Patient complained of no discomfort but deafness was such
that one had to shout into her ears, and there was no history of deaf-
ness previous to the operation. She was nauseated and had vomited
that morning. There was present a mild diarrhea but no abdominal
tenderness. Chest examination was negative. The secretion from the
ears ran into the throat and there was a membrane over the soft palate
and uvula which was not at all painful. Pus escaped freely from the
large openings in the membranes. Exposed bone was detected in the
middle ear of the left side. No mastoid tenderness. Temperature
, 103.6**, pulse 125. Blood examination gave 4,000,000 red, 15,000 white,

hemoglobin eighty per cent. Ear examination was negative.

On the sixteenth day the patient complained of pain about the right
j knee. The urine examination on the following day showed pus, albu-

I min, streptococci and staphylococci. The temperature dropped to 96.4°.

The left mastoid was opened; the bone was hard and white, showing
no signs of necrosis. The sigmoid sinus was exposed throughout its
entire length and found apparently healthy ; the tip of the mastoid was
removed ; and cells far into the zygoma taken away. The only evidence
of inflammation was in the antrum and middle ear where the membrane
was thick and covered with granulations. No openings could be found
into the cranial fossa.

The following day the patient was, at times, in a comatose state and

ORIGINAL ABSTRACTS.

j the right mastoid was opened with the hope of finding some avenue of

j venous infection. A condition similar to the left was found, the sinus

I was exposed and found apparently normal, so it was not opened. The

I patient was in her rocmi an hour after leaving it and her condition

improved so that she recognized her family, but the coma gradually
deepened and she died ten hours later. No autopsy could be obtained.
The most common avenue for septic material to gain entrance to the
circulation from the middle ear and antrum is through the large sinuses.
This could not be discovered. Septic material has gained entrance to
the circulation through the small veins and this has occurred as a result
of osteomyelitis of the mastoid, and the question arises whether suffi-
cient absorption could have taken place from the middle ears and antra
to have caused the fatal result. On account of the sudden marked deaf-
ness the extension of the disease through the labyrinth must be consid-
ered. This might have taken place through the internal meatus, or
along the aquaeductus vestibuli or aquaeductus cochlae, or along the
veins leaving the inner ear. r. b. c.

LARYNGOLOGY.

By WILLIS SIDNEY ANDERSON, M. D., Detroit. Michigan.

ASSISTANT TO THB CHAIR OP LAKTNGOLOGT IN THB DBTKOIT COLLS6B OP MBDICINB

ORBITAL AND MENINGEAL INFECTION FROM THE
ETHMOID CELLS.

James F. McCaw (American Journal of the Medical Sciences,
August, 1905) reports a case in a man, forty years of age, who had
had catarrh and nasal obstruction for years. Severe cerebral symptoms
developed leading to the patient's death.

Postmortem showed that the infection originated in the ethmoid
cells, broke through the os planum, stripping the periosteum from the
roof of the orbit, extending outward and downward to the external
angular process of the temporal bone, and there passed out to form the
subperiosteal collection of pus described in the paper. These cases are
rare but nevertheless cerebral infection from the nose takes place often
enough to warrant more care on the part of practitioners.

THE TREATMENT OF EMPYEMATA OF THE MAXILLARY
SINUS THROUGH THE NOSE.
George L. Richards (Journal of the American Medical Association,
September 16, 1905), divides etiologically these cases into those of
nasal and dental origin. The author advises the treatment of the sinus
by the nasal route. If of dental origin extract the tooth, treat the infec-
tion, and allow the wound to close. When not of dental origin puncture
high underneath the inferior turbinal and wash out the antrum. If this
does not suffice enlarge the opening sufficiently so that it will remain
open during the required time of treatment. The antrum can then be
curetted or packed with gauze as the case requires.

SPASTIC CONSTIPATION.

PROCTOLOGY.

By LOUIS JACOB HIRSCHMAN, M. D., Detroit, Michigan.

CUMXCAL PKOFUSOm OP PKOCTOLOGT IH THB OmtOtT COLLBGX OP MBOICINB.

LOCKING THE BOWELS FOR FROM TEN DAYS TO
TWO WEEKS.

•Howard A. Kelly, in the February, 1906, number of Surgery,
Gynecology, and Obstetrics, concludes, after discussing a series of
twelve cases of plastic work around the rectum, that an enforced
obstipation lasting from eight to fifteen days is of great value in the
management of these cases after operation. His patients are put on
a diet of egg-albumin and water ; this being practically all assimilated,
and leaving no residue in the bowel. The first twenty-four hours, the
patient receives no food whatever; on the second day one and a half
ounces of albumin in water at two feedings; on the third day three
ounces divided into fiyf or six feedings about three hours ap>art; on
the fourth day three and a half ounces in the same manner; fifth day
and daily till the tenth or fifteenth day, six ounces per diem. The
bowel is moved at the end of the period by giving a half ounce of
licorice powder, followed in some cases by an oil enema, and perhaps
the next morning by a half ounce of salts. One of the most important
factors in securing the first evacuation is to^ have the patient lying
in the Sims position, so as to obviate straining. Scybala will not
form even after this long period of intestinal stasis, if milk is eliminated
from the diet, and a perfectly soft stool is procured from the albumin
diet.

"SPASTIC CONSTIPATION.

Dudley Roberts, in the Brooklyn Medical Journal, for March,
1906, claims that this form, in which the retention of feces is due to a
spastic contracture of a part, or the whole of the lower bowel, often
supervenes upon a long-standing atonic constipation. He quotes sev-
eral authorities to support his contention that as high as twenty-five
per cent of all cases of habitual constipation are of this variety.
Usually this spastic condition is due to neurasthenia, hypochondria, or
hysteria, or it may be a reflex from disease of other organs. The stools
are not hard, are of small caliber, or of a "sheep-dung" shape, and are
passed mainly by the pressure of the diaphragm and abdominal muscles.
The large balls of hard fecal matter, so common in atonic constipation,
are absent in this condition. Palpation reveals some part or even the
entire colon contracted to the size of the index finger, and it can be
rolled under the palpating hand.

The treatment of this condition is the treatment of the underlying
neurotic condition. These patients are usually poorly nourished and
undeveloped. Suggestion is of value on those patients who are con-
tinually worrying about the action of their bowels. It is stated that

84 ORIGINAL ABSTRACTS.

the coarse vegetables and fruits, so valuable in atonic constipation,
are strong irritants to the mucosa in this condition. Fats are well
borne, as well as sugars and honey. Warm sitz baths and abdominal
compresses are of value, while cold applications and massage are con-
traindicated. All cathartics are discarded, as the intestine has an over-
plus of contractile force. Hyoscyamus and belladonna in suppositories
are.of distinct value. Rectal and oral exhibition of olive oil is one of
the best forms of treatment. The amount given by mouth is only
limited by the patient's ability to digest it, while the enemata vary from
five to fifteen ounces, warmed to 99° Fahrenheit and given at night and
retained till morning. This is done daily for a week and then gradu-
ally "tapered off." Bromides and chloral are given by mouth in some
cases, and spasm of the sphincter is relieved by forcible dilatation under
gas or ether anesthesia. The cure of the condition may require months
of treatment.

NEUROLOGY.

By DAVID INGLIS, M. D.. Detroit, Michigan.
pROFissom OP Nsmvous and mbntal dissasbs in thb pbtroit collbgs op mbdicinb.

AND

IRWIN HOFFMAN NEFF, M. D., Pontiac, Michigan.

ASSISTANT PHYSICIAN AT THB BASTBKN MICHIGAN ASYLUM.

BRAIN TUMORS: A STUDY OF CLINICAL AND POST-
MORTEM RECORDS BEARING ON THEIR OPERA-

BILITY AND THEIR SYMPTOMATOLOGY.
G. L. Walton and W. E. Paul (Journal of Nervous and Mental
Diseases, August, 1905) contribute a paper based on a study of autopsy
records and specimens of two hundred twenty-one cases of brain tumor.
The number of operative cases from the author's point of view was
three per cent. The clinical features considered are: convulsions,
headache and vomiting, mental symptoms, condition of pupils, and
reflexes. As the writers have been concerned particularly in the inves-
tigation of various reflexes, their interpretation of the findings of the
reflexes is of considerable import. They state that there is need for an
enormous amount of detailed labor before an exact idea can be reached
of the locations of the mechanism concerned in the various- reflexes and
their interpretations. Considerable variation was observed in the con-
dition of both the deep and superficial reflexes in brain tumors; and
although, as they say, their findings were insufficient, they believe that
even the meager findings they noted, suggest that it is worth while to
carry on the study of the brain as an important integral part of the
reflex mechanism. Concerning the knee-jerk, they believe that the fact
is, however, established that the knee-jerk not infrequently disappears
in brain tumor ; and while confessing their inability to critically analyze
all the findings which they recorded, they submit that they are not
easily recognizable with any theory which accepts the spine as the sole

THE SECRET NOSTRUM EVIL. 85

seat of the reflex arcs. The authors conclude the paper with the fol-
lowing suggestion : "The facts here collected are presented merely as
stiggestivc, not as demonstrative or as representing final results. The
main object in this branch of the communication is to direct attention
to the importance of more complete and careful observaticwis of the
locations and the periods in which central growths affect the reflexes,

with a view to furthering the final analysis of the cerebral reflex \

mechanism/' i. h. n. '

THERAPEUTICS.

By DELOS LEONARD PARKER, Ph. B., M. D., Detroit, Michigan.

LBCnimSB OM MATBIIIA MBDICA IN TMB DBTKOIT COLLSOB OV MBDICIMB.

THE SECRET NOSTRUM EVIL.

For some time unmistakable signs have appeared in medical
journals and medical conversations that go to show that the medical
profession is fast becoming wearied with unscientiflc therapeutics.
No more telling sign of this kind has ccwne to the notice of the profes-
sion at large than that exhibited by Frank Billings, M. D., of Chicago,
in a paper entitled "The Secret Nostrum Evil," read before the
American Medical Association, July, 1905, and published in the
December 2, 1905, number of the association journal.

The doctor begins by saying that "proprietary medicine" does not
necessarily stamp a preparation or remedy as a nostrum. Some prop-
prietary medicines are patented, a process that causes their owners
to file at the patent office their formulas and their mode of prepara-
tion. For a small fee any person can get from the patent office a copy
of the information bearing on the remedies that have been recorded
there. Whether or not the patented remedy or remedies are prepared
in conformity with the information furnished the patent office is
another story. Whether or not a patented remedy contains the same
ingredients one year that it does another is also another story. What-
ever the actual facts, however, the profession could easily get on
without patented remedies and fare better with older and simpler
combinations.

The so-called copyright preparations do not differ in any essential
particular from "patent medicines." Both are protected by copyright
for an indefinite period, and both, as a rule, are mixtures of several
ingredients, prepared with the idear not that they will correct disturbed
functions of the body, but that they will sell and bring money to the
coffers of somebody. Doctor Billings quotes Doctor H. C. Wood, Jr.,
as follows:

"A much more elusive and therefore dangerous evil lurks in the
class of mixtures which attempt to cloak their secrecy with a deceptive
show of frankness. I think you will grant that the physician is rarely
justified in the use of remedies concerning which he has no knowledge,
and I maintain that the publication by a drug firm, of whose integrity

g6 ORIGINAL ABSTRACTS.

the physician is absolutely ignorant, of a professed list of ingredients
of some mixture is not sufficient knowledge to parilon or to warrant
the uses of that remedy. In the first place, if the published formula
be correct, it is not enough to know simply the composition of a mix-
ture, the exact quantities must also be known ; there is a vast difference
between the eflfects of one grain and of one hundred grains of opium.
Moreover, there is no means of knowing that the formula is a true
one, for many of these corporations do not hesitate to pervert the
truth."

Preparations of reliable manufacturing chemists, made up of
known ingredients, and recommended to the profession simply for
their palatability or convenience of form are not included in the list
of preparations to be condemned.

Doctor Billings closes his paper as follows :

"What is the cause of the nostrum evil ? There are several.

"(i) Pharmacology and therapeutics are neglected relatively by
many of our medical schools. Anatomy, physiology, pathology, diag-
nosis, et cetera, are emphhasized and too often the usefulness and limit-
ations of drugs are neglected. Too frequently drug nihilism is taught.
If the student were fully taught the physiologic action of drugs, the
art of prescribing, preferably single remedies or in simple combination,
using if he desires the pharmacopeial preparations prepared by reliable
manufacturing pharmacists, and at the same time if he were taught
when not to rely on drugs, but frankly to prescribe for his patient a
course of hygienic measures which alone would accomplish all that
would be required, he would not be the willing dupe of the nostrxun
vendor, as he now is.

"(2) The reput^ible manufacturing pharmacists deserve great
credit for the improvement they have made in pharmaceutical prod-
ucts. They have afforded us official preparation^ in the form of pills,
tablets, syrups, tinctures, extracts, et cetera, which are elegant in
appearance, often palatable and usually potent. For this advance in
pharmacy, a distinct credit to our country, we owe them our thanks.
Unfortunately, many of them have not stopped at this point, but have
manufactured their own special mixtures which are just as objection-
able as the products of the special manufacturers. They, too, have
been active with their agents in visiting physicians and in distributing
'literature.' This encourages drug-giving in specific mixtures for
special symptoms, and is wrong. With one hand they do good work,
with the other much evil is done.

"(3) The nostrum makers at first copied the methods of the reli-
able manufacturing chemists, in exploiting their products, but they
have gone a step farther and have reached a point where one may say
that they have subsidized the medical press. I know I am on dan-
gerous ground when I make this statement, but right here is the chief
cause — and the remedy. How many of our so-called medical journals
are subsidized by medicine manufacturers I do not know, but all physi-
cians know as well as I that there are many, and I do not refer to the

MILK PRESERVATION. 87

so-cailed house organs. I unhesitatingly affirm that one-half of the
medical journals of the country. would be out of existence if it were
not for the nostrum advertisements. Under the circumstances, there-
fore, can we expect these journals to say anything? Need we be sur-
prised that scarcely a journal published the official report regarding
the acetanilid mixtures, when the preparations hit were the best paying
advertisements in the country?

"What is the remedy? Publicity. The enlightenment of the pro-
fession. The truth regarding not only what the preparations contain,
but who makes them. Certainly no honest manufacturer will object
to this last proposition, and no honest physician will put up with less
than the former.

"The Council on Pharmacy and Chemistry has been created to
investigate the nonofficial preparations, to find out the truth about
them, and to publish its findings. It is not necessary to repeat here
the results of the work already done by this body. All physicians
have read, or may read all about it. In my opinion there has been no
movement undertaken by the American Medical Association that will
be so far reaching as this one to rid us of the blight of the nostrum evil.
For the first time, we see the possibility of the elimination of a part,
at least, of this curse to American medicine. It is the first practical
solution offered of a most difficult problem."

EDITORIAL COMMENT.

A QUICK MEANS OF PRESERVING MILK.
The fertility of milk as a culture medium for bacteria, as evidenced
by the rapidity with which organisms increase in the liquid and the
consequent putrefaction, has prompted many efforts by scientists to
discover some ready means for preserving this excellent nutritive
article without altering the character of its composition. Experiments
have demonstrated that in the short space of one hour one cubic centi-
meter of milk may provide for the generation of over six thousand
organisms, and that after the lapse of twenty-four hours this growth
may increase to the magnitudinous proportions of about eleven million.
These observations were made with milk procured under ideal con-
ditions, and obviously the number of microbes would be decidedly
greater were the milk secured from an unhygienic dairy. Refriger-
ation affords an admirable means of checking the growth of bacteria,
but since this process is not always convenient its impracticability for
general purposes is apparent, and indeed the same may be said of the
various other preservative measures known to science.

* * *

It therefore seems appropriate to chronicle a relatively simple
method employed with great success by Renard, a Frenchman, which.

88 EDITORIAL COMMENT.

while not intended as a preservative for long periods, has given prime
results in checking bacterial growth for from two to three days, or
even longer time. An interesting feature in the preservation is that
no antiseptics, such as formol, salicylic acid, or borax, are employed,
the mere admixture of the milk with oxygenized water sufficing to
retard the growth of organisms through decomposition of the water,
the milk being unaffected and absolutely pure and sweet at the termi-
nation of the process. In experiments recently conducted at Rouen,
the investigator obtained excellent results by pouring a two-per-cent
solution of water, oxygenized at twelve volumes, into the milk. The
results already achieved indicate the unadvisability of. employing the
water in stronger than three-per-cent solution, since the decomposition
of a more powerful solution in the milk may lead to undesirable out-
come. After treatment with a three-per-cent solution, milk was pre-
served at a temperature of 1 1 ° centigrade, without the slightest trace
of acidity for ninety-five hours, while preservation could be maintained
for only thirty-two hours at a temperature of twenty degrees.

* lit 3|C

That milk preserved by the above method is absolutely pure was
demonstrated in one of the dispensaries at Rouen, where fifty-seven
infants were fed on the product with uniformly good effect. The
results obtained with boiled milk were not favorable, since the oxygen-
ized water forms certain combinations with the elements of the milk
which have undergone change in boiling. Experiments conducted by
Nicolle and Duclaux upon the comma bacillus, the bacillus of cholera,
the bacillus coli, and certain pus-producing organisms demonstrate
that the oxygenized water process does not destroy pathogenic bacteria
with any degree of certainty. The question may be asked, then, why
is not Pasteurization a more acceptable method, since it insures the
destruction of all organisms, with the possible exception of the tubercle
bacillus? So far as the destruction of bacteria is concerned the
Pasteur method is ideal, but it does not insure preservation, and the
milk, after being subjected thereto, is devoid of many of its nutritive
properties.

ANNOTATIONS,

STUDIES IN SIMIAN VERNACULAR.
Professor Garner, the eminent scientist, who is the discoverer of
the monkey language, is to undertake a second expedition into the
wilds of Western Africa to further his studies in simian vernacular.
The professor carries with him a green cage in which, while making
observations, he is secure from the ravages of the serpent and ferocious
beasts of the jungle. By means of intricate apparatus he was enabled,
on a former expedition, to record certain inarticulate sounds from afar,
which observation taught him to decipher. By means of definite

OBSERVATIONS IN ANIMAL OPTICS. 89

articulation he was able to put to flight an entire nKmkey horde, and
with equal dexterity could assemble the quadrumana by imitating their
expression for "all is well." He learned to recognize their sound for
food and water and for many other things, and could in course of
time converse, so to speak, with the tribe. The contemplated expe-
dition will doubtless be more fruitful in its results, however, as Gamer
will take with him the most perfect phonographs ever produced, that
record may be made of the language of the wild.

THEORIES APPERTAINING TO APPENDICITIS.

Mahler, in a German periodical, discusses appendicitis and theo-
rizes on the factors leading to its causation. The French theory that
particles of porcelain from cooking utensils are responsible for the
affection must be abandoned, since in one thousand operations Krem-
mer found no trace of such substance in the appendix. According to
Mahler, heredity undoubtedly plays an important role in the causation
of the disease, as is evidenced by repeated attacks in the same family.
This author ventures the suggestion, however, that meat may be a
provocative factor, and cites the prevelance of appendicitis in America,
England, and the city of Hamburg, where meat is the chief food staple,
in support of this idea. The fact that appendicial attacks occur more
generally among people of wealth in Europe is further empharfzed, as
the economic- conditions existing abroad preclude the poorer classes
from meat indulgence.

OBSERVATIONS IN ANIMAL OPTICS.
Doctor Lindsay Johnson, the English ophthalmologist, who has
been studying the optic apparatus of various animals, has made some
valuable discoveries which, according to Lankester, the noted zoologist,
will require the entire rearrangement of one section of zoology. That
man bears a close relationship to the lower forms is reiterated in
Johnson's findings. The similarity of the eye of man and that of the
anthropoid apes, according to this investigator, is suggestive of the
Darwinian theory. Each is equipped with a highly complex arterial
and venous system, and parallel vision is characteristic of both. The
observations disclose the probability that the canine family is a product
of two ancestries, since in the dog may be found both the round- and
oval-eyed types. The first species is undoubtedly the result of an
admixture of hyena blood. The eye of animals exposed to the chase —
the squirrel, hare, et cetera — is so situated that the vision is unlimited,
the animal being able to see in all directions, without altering position.
The fact was likewise observed that all rodents squint, but the signifi-
cance of this peculiarity remains unascertained. The parallel vision is
especially typical of the higher forms, and the lower in the scale of
development the animal is classified the less liability is there to this
optical adjustment. Perhaps the most interesting feature of Johnson's

go EDITORIAL COMMENT.

research is his theory as to the nature of the corpus nigcr in the eye of
the horse, which has caused so much speculation among scientists.
This structure is found in nearly all tropical animals — the camel, onegar,
and antelope — and fulfills the function of protecting the eye from the
sun's rays. Its presence in equinae affords a possible means of tracing
the ancestry of the horse.

CONTEMPORARY.

PHYSICIANS AND PHILOSOPHERS.

[PROPISSOll CHAHLBS WILLIAM SUPER, OP OHIO UNXVBRSITT, IN POPULAH SCIBNCB MONTHLY.]

{C^mtinutd from page 44.)

Apropos of the intimate relationship existing between the stu-^.v
of nature and the healing art, we find that the Romans as early as the
time of Cicero called a natural philosopher physicus, while the science
itself was called physica, both words having been borrowed from the
Greek physikos, that which pertains to nature, from physis, nature,
in the somewhat restricted sense of the term as used in antiquity. But
in medieval Latin physica had become the equivalent of mededna and
physicus that of medicus. In the older English, physic means both
natural philosophy, the modern physics, and the medical art as well as
drugs. The restricted signification 'to purge* and 'a purge' is com-
paratively recent.

Shakespeare uses both doctor and physician, the former generally in
the sense of teacher. Doctor also occurs in Middle English and later
Chaucer speaks of a 'doctour of Phisik.' In classical Latin the term
doctor means teacher, a sense in which it is used by Cicero, Horace
and others. It had no connection with medicine. In modern French
physicien means one who occupies himself with physics, but in the
older language it had the signification of the English physician. The
French medecin, physician, is evidently from the Latin medicinus, a
derivative from medicus, while our medicine, a remedial drug, is from
the same word in the feminine gender. In German the connection
with the English physician is preserved by Physikus alone, a term used
to designate an official whose functions correspond in the main with
our health-officer. Here too the term Doktor has long since usurped
the more specific Artst, and Doktorei is occasionally used for medicine,
'doctor's stuff.' The Gothic word lekeis, which is the Anglo-Saxon
laece and the English 'leech' has nothing in common with either
except the meaning. This term doctor again brings to the physician
the same title that ib borne by the scholar. Although it is given in
several departments such as law, theology, music, philosophy, and so
on, to the common man both in German and in English countries the
doctor represents only the physician. This is explained by the fact
that in most communities the only man or men bearing the title were
physicians. Of late years, however, especially in the United States,

PHYSICIANS AND PHILOSOPHERS. 91

doctors of divinity have becwne so common, not to mention other
doctors, that the designation has reached the stage of painful uncer-
tainty. What it now represents can only be determined by an investi-
gation of each individual on whom it has been conferred.

No more convincing testimony to the small progress made in the
healing art from the earliest times until a little more than a century
ago need be asked for than is offered by a comparison of the average
length of human life as given by Herodotus and that currently
accepted until quite recently — three generations to a century. In fact
most life insurance associations have not yet learned that this average
is above forty years. Anatomy had made great progress and the struc-
ture of the body was minutely known, but until the germ theory of
disease and antisepsis were established, therapeutics was largely a
matter of tradition and routine; of empiricism and individual skill.
When one reads of the incessant wars that kept a portion of the male
inhabitants constantly occupied in military enterprises, directly or
indirectly, one is inclined to believe that the average of human life
must have been shorter than it was held to be twenty or twenty-three
centuries ago. There is no room to enter upon a discussion of the
problem here; suffice it to say, the loss from disease was probably no
greater, and the losses in the armies probably much less relatively than
in modem times. For it is well known that the killed in battle are but
a small portion of those whom war deprives of life. It is probable
that never before or since has any country suffered such ravages as
did Germany during what is called the thirty years war. That the
sanitary condition of ancient Greece must for the most part have been
fairly good is attested by the rapid recuperation of most of the city-
states after a disastrous war. But then there were no large cities
like those of modern times, in which the population increases much
faster than the adoption and enforcement of sanitary measures.

It will hardly be considered surprising that disease in any form
should early have stimulated men to reflection. This is true at least
of those living under conditions where there was more or less freedom
of action and where affairs had not yet settled down into the lethal
routine that characterized the social life of most of the people of the
ancient world anterior to the appearance of the Greeks. The succes-
sion of day and night; the changes of season that follow each other
regularly, and the meteorological conditions that accompany them,
would be taken as a matter of course. But the vicissitudes of the
human system, whether gradual, rapid or sudden, when not the result
of accident or attributed to the malevolence of evil spirits, naturally
led to inquiry as to their causes. The next step was in quest of
prophylactics and curatives. This sort of reasoning, of philosophy,
was not obnoxious to the charge that Socrates brought against the
philosophy of his day, namely, that it was concerned wholly with
things that were of no benefit to any one and with problems to which
no answer could be found.

^ [to be continued.]

d2 MEDICAL NEWS.

MEDICAL NEWS.

PROFESSOR ERNST ZIEGLER, PATHOLOGIST.

Doctor Ziegler^ whose death occurred recently, was born in the
neighborhood of Berne, Switzerland, in 1849. He studied medicine in
his native city and also at Wiirzburg, and received his doctor's degree
at Berne in 1872. He qualified as privatdocent at Wiirzburg, occupy-
ing this position for three years, when he went to Freiburg in Breisgau
as assistant and later became extraordinary professor. In 1881 he filled
the chair of pathology and morbid anatomy at Ziirich, in 1882 he went
to Tiibingen in a similar capacity, and in 1889 returned to Freiburg,
where he remained as professor of patholc^y until the time of his
demise. Doctor Ziegler was a prolific writer and investigator, and con-
tributed articles on inflammation, tuberculosis, rickets and neoplasms to
various periodicals, but the greatest expression of his work is embodied
in "Ziegler's Pathology," which was first published in 1881, and through
which he is chiefly known to American students and physicians. Besides
being professor and author he was likewise editor of two of the most
important German publications on pathology — ^the Beitrdge zur allge-
fneinen Pathologic und pathologischen AnatonUe and the Zentralblatt
fiir allgemeine Pathologic und pathologische AnatonUe. He was
engaged in the revision of his text-book at the time of his death and
had so far progressed with the work that with slight further revision
it may be accepted as the final expression of his opinion on pathology.
He was highly esteemed as a man, and his ability as a lecturer has
been attested for long by students from many climes.

MINOR INTELLIGENCE.

A BILL has been introduced in the Massachusetts legislature to pro-
hibit the publication of advertisements referring to sexual diseases.

A LATE ordinance of the city of Toronto provides that the houses of
persons succumbing to tuberculosis shall be disinfected by the local
health officers.

MiLAN^ Italy, is designated as the next meeting place of the Third
International Congress of Electrology and Radiology, which will con-
vene in Sptember, 1906.

The Protestant missions have been instrumental in establishing the
Union Medical College, of Pekin, China, which institution was opened
for instruction February 13, 1906.

A BILL has been introduced in the New York legislature forbidding
the marriage of imbeciles, epileptics, insane, or feeble-minded persons.
The measure also prohibits the marriage of sound persons to feeble-
minded.

MINOR INTELLIGENCE. 08

The announcement is made that Karl von Noorden has been
appointed to fill the chair at the University of Vienna made vacant by
the death of Professor Nothnagel.

Queen Amelie, of Portugal, who is a doctor of medicine, will be
honorary president of the Fifteenth International Medical Congress,
which meets in Lisbon, April 19, 1906.

The Health Department of Havana reports that three patients, suf-
fering from mild attacks of yellow fever, are still confined in Las
Animas Hospital. No new cases have recently been reported.

The Iowa State Board of Medical Examiners has made a ruling to
the effect that diplomas granted by schools which allow advanced stand-
ing for work done outside of medical schools shall not be recognized.

The City of Mexico is in the throes of an epidemic of typhus fever.
The disease is attributed principally to bad sanitary conditions in the
city, and stringent measures toward remedying them are being enforced.

The plans submitted for the new army hospital at Washington
have been approved by Secretary Taft. The estimated cost of the
building is $300,000, Congress having limited the appropriation to this
amount.

The Chicago Women's Club has inaugurated a campaign against
venders of impure milk, and the various female organizations of the
city will be asked to subscribe $1,500 annually to provide a salary for a
competent milk inspector.

Doctor Lehman H. Dunning, of Indianapolis, a well-known gyne-
cologist and for several years professor of gynecology and abdominal
surgery in the Indiana Medical College, died at his home on January 4,
1906, aged fifty-five years.

Doctor Clara Marshall has resigned the Chair of Materia
Medica and Therapeutics in the Woman's Medical College of Pennsyl-
vania. The doctor has been connected with the teaching force of the
institution for over thirty years.

A SITE has been chosen in the town of Pittsford for Vermont's new
tuberculosis sanitorium. The institution is a gift to the state from
Senator Redfield Proctor, and the projectors anticipate the completion
of the buildings by next winter.

The passage of a bill in the New York Assembly, on March 6, pro-
vides for the appointment of two more health commissioners for the
city — one for the Boroughs of Manhattan, Richmond, and Bronx, and
one for the Boroughs of Brooklyn and Queens.

The will of the late Doctor George S. Hyde provides that $50,000
be turned over to the Harvard Medical School upon the death of E. P.
Hyde and Mrs. Aniie M. Sargent, brother and sister of the deceased.
The doctor was connected with this institution prior to his demise last
year.

94 MEDICAL NEWS.

At the twenty-ninth annual meeting of the Illinois State Board of
Health, which was held recently at Springfield, Doctor George W.
Webster, of Chicago, was elevated to the presidency, and Doctor James
A. Egan, of Springfield, was reelected to the secretaryship.

Dissension exists between the physicians and druggists at Bayonne,
New Jersey, because the latter persist in counter prescribing. A state
law prohibits any person except a physician frc«n prescribing for the
sick, but the druggists have engaged counsel and will institute a test
case.

A SUM of $8,000 has already been subscribed toward the erection of
a $10,000 memorial to the late Doctor Joseph Leidy in consideration
of his invaluable contributions to the natural sciences. The monument
will be presented to the city of Philadelphia, the field in which the
scientist worked and died.

Reports recently submitted to the Mississippi legislature by the
State Board of Health disclose an expenditure of over $43,000 during
the past year in consequence of the yellow fever epidemic. Fifteen
localities were infested, the total record showing eight hundred thirty-
seven cases and sixty-one deaths.

The sum of $13,000 was realized from the New York German
charity ball which was held in January. Of this amount $2,300 was
given to the German Hospital and Dispensary, and smaller amounts
were donated to Saint Mark's Hospital, the West Side German Dis-
pensary, and Saint Francis' Hospital.

Doctor Samuel R. Wooster, late president of the Grand Rapids
Academy of Medicine, died from the effects of a surgical operation on
February 6, aged sixty-six years. Doctor Wooster was a graduate of
Yale and during the Civil War was connected with several Michigan
regiments in the capacity of army surgeon.

»The will of Charles L. Yerkes, the deceased street railway mag-
nate, bequeathes $800,000 for the purchase of a site and erection of hos-
pital buildings thereon in the Borough of Bronx. Provision is also
made for the maintenance of the institution. The income arising from
a sum of $5,000,000 will be utilized for this purpose.

Professor Ernst von Bergmann, the eminent German physician,
has been raised to life membership in the upper house of parliament by
the German Emperor. Professor von Bergmann is the author of the
work on surgery which bears that name, and is the first physician to be
elevated to the dignity of membership in the German parliament.

The next meeting of the Association for the Advancement of
Science will be held in New York City on December 27, 1906. At the
recent meeting in New Orleans the following officers were elected for
the ensuing year: President, William H. Welch, of Johns Hopkins;
general secretary, John F. Hayford; secretary of council, F. W.
McNair.

AUTOINTOXICATION IN DISEASE. 95

After several setbacks the osteopaths have renewed their efforts to
establish recognition of their cult in the state of New York. The
Davis bill, which is intended to create an osteopathic examining board
under the Regents of the State University, was recently given public
hearing before the Senate Judiciary Committee. Several physicians
and laymen spoke in opposition to the bill, contending that its passage
would permit persons unqualified, by reason of meager medical knowl-
edge, to engage in medical practice. The only supporters of the bill
were four osteopaths from different New York cities.

RECENT LITERATURE.

REVIEWS.

THE READY REFERENCE HANDBOOK OF DISEASES OF

THE SKIN.*

This last edition of Doctor Jackson's well-known and popular hand-
book contains the addition of much new material in text and illustra-
tion. It is among the best of handbooks, and while the alphabetical
arrangement of diseases does not commend itself to the specialist or
teacher, it will appeal to the practitioner who wishes to get at the gist of
pathology, diagnosis, and treatment of a given case — if only tentatively
— ^in the shortest time. The style is clear and concise, and the book will
advance the position the former editions held as a valuable and trust-
worthy guide in the care of diseases of the skin. A useful appendix
contains suggestive formulae for external applications, as well as for
internal medication. w. f. b.

♦By George F. Jackson, M. D. Fifth edition, thoroughly revised,
making a 12-mo. volume of 676 pages, with ninety-one engravings and
three colored plates. Cloth, $2.75, net. Lea Brothers & Company,
Philadelphia and New York, 1905.

SELF-POISONING OF THE INDIVIDUAL.*
The reprinting of this well-known work seems to indicate a con-
tinued demand. This being so, it is unfortunate the whole book was
not rewritten. It is hard to patch the stuff of the last twelve years'
work upon the well-worn garment of the former time, and Doctor
Oliver has only made this clearer by his well-meant endeavors. The
things that made the first edition popular are still here — ^the assurance
of certainty, the simple faith in antiseptics, but they fall on stonier
ground than before. Let us hope the next edition will give us what
the first promised. G. d.

♦By Ch. Bouchard^ Professor of Pathology and Therapeutics;
Member of the Academy of Medicine and Physician to the Hospitals,

96 RECENT LITERATURE.

Paris. Translated, with a Preface an^ New Chapters added, by
Thomas Oliver, M. A., M. D., F. R. C. P., Professor of Physiology,
University of Durham ; Physician to the Royal Infirmary, New Castle-
Upon-Tyne; formerly Examiner in Medicine, Royal College of Physi-
cians, London. Second revised edition. Crown octavo, 342 pages.
Extra cloth. Price, $2.00, net. F. A. Davis Company, Publishers,
1914-16 Cherry Street, Philadelphia.

PRACTICAL PEDIATRICS.*

This treatise on the medical and surgical diseases of childhood is
certain to rank as one of the best books of the kind for the busy practi-
tioner or for the student preparing for examination. It is brief and to
the point, as the author has omitted superfluous material. The Ameri-
can translator has made many additions and inserted notes which
enhance the value of the book. An excellent chapter devoted to the
"Materia Medica and Theurapeutics of Childhood" concludes the work.
The book is most attractively executed and the parts are well arranged.

A. D. H.

*A Manual of the Medical and Surgical Diseases of Infancy and
Childhood. By Doctor E. Graetzer, Editor of the Centralblatt fur.
Kinderheilkunde and the Excerpta Medico. Authorized translation,
with numerous Additions and Notes, by Herman B. Sheffield, M. D.,
Instructor in Diseases of Children, and Attending Pediatrist(0. P. D.)
New York Post-Graduate Medical School and Hospital ; Visiting Pedi-
atrist to the Metropolitan Hospital and Dispensary, et cetera. Pages
XII-544. Crown octavo, flexible cloth, round comers. Price, $3.00
net. F. A. Davis Company, Publishers, 1914-16 Cherry Street,
Philadelphia.

THE PHYSICAL EXAMINATION OF INFANTS AND
YOUNG CHILDREN.*

An inexpensive, neat little book, full of many practical suggestions
for those who desire to acquaint themselves with the various methods
of examining children. The illustrations are clear in detail. There is
only one subject of importance in the examination of children the
author fails to clear up for the reader, that is, how to induce the child
to become so "pleased to meet you." The majority of the illustrations
present a smiling nurse and doctor and a perfect angel of a patient,
almost like the catatoniac whose arm stays where you put it.

*By Theron Wendell Kilmer, M. D., Adjunct Attending Pediatrist
to the Sydenham Hospital ; Instructor in Pediatrics in the New York
Polyclinic Medical School and Hospital, New York; Attending Phy-
sician to the Summer Home of Saint Giles, Garden City, New York.
Illustrated with fifty-nine half-tone engravings. i2mo, 86 pages.
Bound in extra cloth. Price, 75 cents, net. F. A. Davis Company,
Publishers, 19 14- 16 Cherry Street, Philadelphia.

% Jtesician aiilr Surgeon

A PROFESSIONAL MEDICAL JOURNAL.

VOLUMB XXVIII. MARCH, 1906. NUMBER III.

ORIGINAL ARTICLES.

MEMOIRS.

CONGENITAL LUXATION OF THE HEAD OF THE RADIUS.*

REPORT OF TWO CASES. ANALYSIS OF FIFTY-ONE CASES. SUMMARY.
CER TAIN O THER CONSIDER A TIONS. COXCL USIONS.

By WILLIAM E. BLODGKTT. M. D.. Detroit. Michigan.

The concurrence of two new cases of congenital luxation of the
head of the radius, with failure to find a thorougli review of the sub-
ject directly based on the observed facts, has led to the present paper.
Nearly all the cases here included are referred to by Powers,* Blumen-
thal,^ Bonnenberg,^ or Abbott,* to whom the author is indebted for
most of his data; but it is believed that a uniform analysis of each
case and collation and summary of the entire group is needed.

The plan of the paper, therefore, is to (I) report the author's two
cases, (II) analyse the fifty-one cases, (III) summarize the group,
(IV) consider certain features of the subject not covered by the sum-
mary, and (V) draw conclusions.

I.— REPORT OF CASES.

Case L — A girl, fifteen years old. No miscarriages or other sug-
gestion of syphilis in family history. No abnormalities in parents or
in brothers or sisters. The trouble in the arms was first noticed when
it was found that the young baby could not hold a lump of sugar on
either palm. Three years ago while arranging her hair, the patient

♦Presented by invitation at the nineteenth annual meeting of the American
Orthopedic Association, at Boston, June 6-8. 1905.

98 ORIGINAL ARTICLES.

had sudden pain in the left elbow upon attempting to extend it; no
pain when the elbow was at rest in flexion. This difficulty in exten-
sion continued several months. An anesthetic showed that the obstacle
to extension was muscular. The difficulty gradually disappeared.
Neither elbow has at any time been swollen or tender. No other
deformities. Excellent general health. The chief complaint is of par-
tial disability of either arm, illustrated by the patient's inability to
grasp a plate or a spoon with the thumb on the upper surface. There
is also unusual liability to fatigue in the arms.

FIGURE I. — RIGHT ELBOW, CASE I, SHOWING ANTERIOR DISLOCATION OF HEAD OF
RADIUS, ELONGATION OF RADIUS, AND FUSION OF RADIUS AND ULNA.

Patient is well developed and nourished. Examination of parts
other than the arms, negative. The forearms are fixed in respect to
rotary motion in full pronation. Flexion and extension are free and
strong. Hyperextension beyond straight sixteen degrees on left and
twenty degrees on right. Relation of condyles and olecranon appar-
ently normal. Distal to the external condyle and the capitellum, the
space iiormally occupied by the head of the radius is vacant. On the
llexure surface of the elbow, anterior to this vacant space, is plainly
felt a hard, globular body, size of the index finger, moving with

CONGENITAL LUXATION OF RADIAL HEAD.

movement of the forearm. The tendon of the biceps passes down on
the inner side of this body. No atrophy apparent. No other abnor-
malities of arms. The two elbows are alike.

Radiographs show on each side an anterior luxation of the radial
head, excessive length of the upper end of the radius, absence of the
normal slight anterior concavity of the lower end of the shaft of the
humerus, and cancellated bone fusion of the radius above the tubercle
with the ulna. Radiographs of the forearms and wrists show nothing
abnormal, except that bones are small for age.

FIGURE II. — LEFT ELBOW OF NORMAL GIRL, SAME AGE. SAME POSITION AS IN

FIGURE I.

The temporary inability to extend the left elbow without pain is
to be explained by a sprain, to which such an imperfect joint would
be especially liable. Excision of the radial head, the only operative
procedure to be considered, was believed unindicated by the amount
of disability present.

Case II. — (Through courtesy of Doctor Daniel LaFerte, Detroit).

100

ORIGINAL ARTICLES.

A boy, six years old. No syphilitic history or abnormality in family.
Since birth, the forearms were fixed in extension and pronation.
Radiographs taken two years ago show bilateral, anterior luxation of
the radial head, elongation of the upper end of the radius, and no bone
fusion. Owing to the permanent extension, the disability was great.
About two years ago, Doctor LaFerte excised the upper end of the
radius on each side, taking care not to disturb the insertion of the

FIGURE III.-

LEFT ELBOW, CASE I, SHOWING DISLOCATION ELONGATION, AND FUSION.
PRONATKD POSITION.

biceps. This was followed by riianipulative mobilizations, which, how-
ever, were discontinued by the patient sooner than advised. The child
also had double club-foot, which was operated on with good result.
When the boy was seen by the author two years after the operation,
the mother stated that the boy could now feed himself, and that the
arms were improved, although the child still grasped objects with
the thumb underneath. Passive flexion on both sides was found to
reach to a right angle, and passive extension to within twenty degrees
of straight; no power, however, on either side in flexion or extension.

CONGENITAL LUXATION OF RADIAL HEAD.

101

The right elbow is permanently pronated, and the left is in ninety
degrees of pronation and allows a few degrees of rotary motion.

Radiographs show what appears to be a partial regeneration of the
heads of the radii in the anterior position.

FIGURE IV.-

-LEFT ELBOW OF NORMAL GIRL, SAME AGE.
FIGURE III.

SAME POSITION AS IN

II.— ANALYSIS OF FIFTY-ONE CASES.

C/3

is Q

5 .

2
0

i«

-< <

oi Z

''■

CASE

n
0

THER

BFORM

lES

REMARKS

>-)

bd H

b. <

0 Q H

(i) Bonnenbcrg*

For-
ward

Free flex'n.
155" ex-
tension.

Yes

Excision head of ra-
dius and lower end
ulna. Osteotomy
shaft radius to
straighten. Result:
pronated position,
with slight passive
and no active supi-
nation; free flexion
and extension.

(2) Dupuytren*

Both

Back-
ward

Yes

Necropsy.

102

ORIGINAL ARTICLES.

(3) Dupuytren*

(4) Servier'

(5) Herskovitz*

(6) Homphrey*

(7) Mitscherlich"

(8) Allen"

(9) Pyc-Sinith»2

(10) Phillips"

{ii)Hccle"

Both

•J

Back-
ward

Back
ward

Back

ward

For-
ward

Back

ward

Back
ward

Back-
ward

Back
ward

Supination
limited.
No mention
flexion or
extension.

Half pro-
nation to
fall prona-
tion.

Free flex-
ton. 120''
extension.

Extension

free.
Flexion on

R. to 7o%

L.to 110**.

Snpinated.

Extension
only to
right an-
gle. No
rotation.

Extension
free.

Flexion
nearly
free.

Semipro-
nated.

Slight ro-
tation.

Normal,
but supi-
nation
weak.

o <

Yes

•< •<

at Z
O ^

^ 9

k. <

Yes

Absence
lower
part of
left ulna.

Club-
foot

Defect of
knees.

Forearm

concave

toward

radical

side.

Defect

lower

ulna.

Club-
foot

Hyper-
trophy
external
condyle.

REMARKS

Radial head, upon
rotation of farearm,
circumducts in circle
of 3 c m. radius.

Necrcipsy only.

Complete excision
elbow. Death.
Specimen shows no
contact at all be-
tween head of radius
and ulna.

Necropsy. No his-
tory of presence in
early life.

Noticed early in life.
In family of eleven,
eight had joint de-
formities.

Noticed shortly after
birth.

Noticed early in life.
Loose- jointed. In-
telligince backward.
Right always luxated
— left, usuidly.

CONGENITAL LUXATION OF RADIAL HEAD.

103

CASE

(i2)Machenhauer>*

(13) Adams^*

(14) Adams^'

(15) Dcvillc"

(16) Senftlebcn**

(17) Adams'*

(18) Adams"

(19) Cruvcilhicr**

(20) Cruveilhicr**

(21) Sandifort*

(22) Sandifort*

(23) Dubois*

(24) Vcrneil*

(25) Sandifort*

Both

<
X
D
•J

For
ward

One

R
One
One
One
One

Out-
ward

Out.
ward

Out-
ward

Back-
ward

In-
ward
and
for-
ward

Extension

to 165°

Flexion to

Supination
and prona-
tion free.

Free ex-
cept in ex-
tension.

No exten-
sion or
flexion.

Supination
and prona-
tion free.

Freer than
normal.

Normal.

In position
of semi-
flexion
and full
pronation.

Extension
limited.

No supina-
tion.

Pronated.

No supina-
tion.

«3

< u.
o o

Yes

2 in.

Yes

< <
t4 Z

o ^

^ s

u. •<

Yes

gas

H M M

O Q H

No.

Other de-
formities
of elbow.

Defects
in other
joints.

Deficien
cy middle
of ulua.

Defici-
ency
shaft of
ulna.

Forearm
concave
on ulnar
side.

Necropsy. Radial
head excessively
large.

Necropsy. Soft parts
normal. Fibrous
band in place of mid-
dle of ulna. Forearm
concave on ulnar side

Fibrous cord in place
of middle of ulna.
Forearm concave on
ulnar side.

Preparation. fio
trace of capitellum.

Preparation. "Cari-
ous" process in joint.

Preparation.

Necropsy.

Preparation.

104

ORIGINAL ARTICLES.

CASE

Back

ward

1 '

Suptnafion

limited.

Semiflexed*

c ■<

^ 1

0 ^
-1 a:

Yes

< <

REMARKS

(26) Bessel-

Hagen»

External
condyle
hypertro-
phied.
Gigant-
ism of

Excision head of rad-
ius, foUowed hyman-
ipulalions under an-
eiithesia. Result
one year after opera-
lion: normal mobil*

arms*

ity*

(27) Bessel-

Hagen^

back-
ward

AH motions
limited.

Semipro-
nated and
semiflexed.

Ves

Various

exostoses

and de-

fecis.

Forearm

smaller

Ulna undeveloped,
and deficient at car-
pal end.

!■

and con-

cave on
I ulnar
side.

(28) Bessel-

Hagen»

Back
ward

Extension
onlv

limited*

Ves

Varioui*
defects*
Forearm
smaller
and con-
cave on
ulnar
^ide.

Eiead circumducts
in rotalioD of £ore-
arro.

(29) Smith"

One

For-
ward

From 90^
to nearly
straight
Pronation
and supina-
tion lim-
ited.

External
condyle
enlarged*
Congeni-
tal luxa-
tion of
wrist and
knee.

No trochlea or capi-
tellum<

(30) Smith"

One

Slight ex-
tension
from 90*"
permanent
flexion.
Pronation
and supi-
nation
limited.

Yes

External

condyle

enlarged.

Deficient

ulna.

No capitellum. Hole
for radial head be-
tween imperfect
trochlea and exter-
nal condyle.

(31) Toppich»

(«

Free

Yes

Tuberculosis other
elbow.

(32) Leisrink**

Both

Extension
and flexion
nearly free.
Supination
and prona-
tion much
limited.

Luxata-
ble left
ulna.

Resuscitated after
delivery by vigorous
means. First noticed
at third year.

CONGENITAL LUXATION OF RADIAL HEAD.

105

CASK

(33) Abbott*

(34) Abbott*

(35) Abbott*

(36) Abbott*

(37) Abbott*

{38) Abbott*

(39) Abbott*

<40) Abbott*

Both

For-
ward

Both' "
Both '*

Buih

Botb "

M Br>th

Back

ward
and
in-
ward

4 bi

Extenfiion

and flexion
free. Fixed
in fietni-
pronation.

Ye>

Yes
witli

cen-
ter of
oulfi

CMtEw

Ex ten a ion
and flex ton

free. Fixed
in fieroi-
pronation.

Yes

V€S

As above,
but left has
only sHgbt
check to
supination.

Ves

Ves
It

Extension
and fleaion
free. Fixed
in £]mi-
pronation*

Yes 1

Ye«

Yes

Ye»

All motions
restricted.

Yes

Club-
foot.
Disloca-
tion
patella.

Noticed early in life.
The presence of the
lesser sigmoid cavity
and the smooth arti-
cular cartilage on the
head indicate to Ab-
bott that the primary
lesion is the over-
growth of head and
neck, resulting in fu-
sion (due probably to
the center normally
forming the coronoid
process).

Noticed early in life.

Noticed early in life.
Not seen by Abbott,
but credibly reported
to him to be entirely
similar to his other
cases.

Noticed early in life.
Not seen by Abbott,
but credibly repoted
to him to be entirely
similar to his other
cases.

These seven cases
occured in one fami-
ly, covering four gen-
erations.

Dissection.
Apparently due to
deformity of lower
ends of humeri.
Capitellum well-
formed, and larger
than usual.

106

.ORIGINAL ARTICLES.

(41) Abbott^

(42) Voigt"

(43) Schmidt"

(44) Blumentb&l'

(45) Powers*

(46) Ambard"

(47) Bcrgtold*

(48) Hamilton"

(49) Guerin*"

One

Both

Back
ward
and
out-
ward

Back
ward

For
ward

Back
ward

Extension

slightly

limited.
Flexion

free.

No supina-
tion beyond
midpoint.

Excessive
flexion to
140° of ex-
tension on
R. Free
flexion and
extension
on L. Al-
most no
supination

For- Almost no

Both

ward
and
out-
ward

Out-
ward

Both

Both
Both

supination
No active

flexion.
Passive

flexion to

Free and
strong.

For-

word

'^ 9
o •<

Extension
and flexion
free. Fixed
in prona-
tion.

Normal.

Yes

< <

o ^

^ 5

u. <

Yes

H M S
O Q H

Defect of
radius on
other
side.

Defect of
radius on
affected
side.

Forearm
on R.
shorter,
and rad-
ius con-
cave in-
ward.

Nasal
caries.
Syphili-
tic?

Yes

Noticed early in life.
Capitellnm well-
formed, and larger
than usual.

Radial bead luxata-
ble upon extension.

Sister, father, and
paternal grand-
father said to have
same deformity.
Radiographs.

Noticed three days

after birth.

Left arm shorter.

Radiograph.

Noticed early in life.
Applied for treat-
ment for excoriations
over prominence of
head of radius on
outer side of either
elbow.

Luxation believed by
Ambard to be con-
genital effect of
hereditary syphilis.

Generally loose-
jointed.

CONGENITAL LUXATION OF RADIAL HEAD.

107

CASE

0 0

^ 9

THER

EFORM

lES

REMARKS

2 2

D S5

•J

M M

U. «<

0 Q H

(50) LaFertd«»

Both

For-

Nearly fixM

Yes

Club-

Noticed early in life.
Excision radial

ward

in exten-

foot.

sion and

heads. Result after

pronation.

two years: passive
but no active flexion,
no rotary mobility.

(51) Blodgett**

Both

Extension

and flexion

free.
Fixed in

pronation.
Hypcrex-

tensible.

Yes

Noticed early in life.

III.— SUMMARY.

(J) Sex.

Male

22. 61.1%.

Female

14. 38.9%.

Unrecorded

15-

Of bilateral cases :

Male

17. 77.3%.

Female

5. 22.7%,

Unrecorded

(2) Side,

Both

25- 50.0%.

One only

25. 50.0%.

Unrecorded

Of unilateral cases :

Right

9. 56.2%.

Left

7. 43.8%. .

recoi

rded

•

(j) Direction of Lujfation.

Backward

Forward

Outward

Inward

Unrecorded

23.

46.0%.

20.

40.0%.

12.0%.

2.0%.

In the bilateral cases the direction of luxation was always the same on the
two sides.

108

ORIGINAL ARTICLES.

(4) Mobility.
Table A.
Backward. Forward. Outward. Inward. Unrecorded. Total.

Freer than

normal

Normal i. 5.6%.

Restricted 17. 94-4%.

Unrecorded 5.

1. 16.7%.
I- 5.9%. 3. 50.0%.
16. 94i%- 2. 33-3%-
3.

I. 24%.

5. 11.6%.

37' 96.0%.

Table B.

Extension.
Flexion.
Pronation.
Supination

Free or
nearly free
(including cases
fixed in the ex-
treme of motion.)

21. 60.0%. 14. 40.0%.

22. 64.7% 12. 35-3% •
27. 62.8%. 16. 37.2%.
12. 27.9%. 31. 72.1%.

Restricted. Unrecorded.

16.

17.
8.
8.

Table C*
Backward. Forward. Outward. Inward. Unrecorded. Total.

Extension
free or
nearly free.

Flexion
free or
nearly free.

Pronation
free or
nearly free,
including
cases fixed
in full
pronation.

Supination
free or
nearly free.

3. 13.0%. 13- 65.070. 5- 83.3%-

II. 47.8%. 6. 30.0%. 5. 83.3%.

21.

22.

14. 60.9%. 5. 25.0%. 6. 100.0%.

2. 8.7%. 4. 20.0%. 5. 83.3%.

(5) Elongation Upper End of Radius.

In backward luxations 18.

IS.

27.

12.

In forward luxations
In outward luxations
Direction not recorded
Total

78.3%.
75.0%.
66.7%.

4.
I.
38. 74.5%

*The precentages in Table C. are based on the whole number of luxations in the
direction under consideration; thus 100 % of the outward luxations have free pronation
because six have this movement free and there are only six outward luxations in all.

CONGENITAL LUXATION OF RADIAL HEAD,
(d) Bone Fusion Upper Part Radius and Ulna.

10»

In backward luxations
In forward luxations
In outward luxations
In inward luxations
Total

6 (4 single, 2 double).

ID (4 single, 6 double) .

I (single).

17 (9 single, 8 double).

26.1%.
50.0%

33.3%

::ases with fusion:

No rotation
Almost no rotation
Unrecorded
Pronated position
Semipronated position
Unrecorded

14-
2.
I.
6.
7.
4.

(7) Other Deformities.

Bone deficiency in forearm 7
Club-foot 5.

Other deformities of elbow.

(besides those directly refer-
able to the luxation of the head
of the radius)

Lateral curve of forearm.
(3 concave on ulnar side,
I concave on radial side).

Other joints defective

Total

-22.

431%.

IV.— CERTAIN OTHER CONSIDERATIONS.

(i) Incidence,

Stimson'^ quotes Kronlein's'* statement *'that the records of Von
Langenbeck's polyclinic show 90 congenital dislocations of the hip,
5 of the shoulder, 2 of tlTe head of the radiuis, and i of the knee.''
Congenital dislocation of the hip, the cotnmonest of the congenital
dislocations, was found by Chaussier once m 23,293 infants born at
the Maternite, although Parise, in 332 hip dissections of all the children
who died at the Hospital 'des. En f ants Trouves, found congenital dis-
location of the hip three times.^*

(2) Congenital Character.

The arguments for the congenital character of these dislocations
of the head of the radius are:

(i) Discovery of the condition early in infancy, without preceding
trauma.

(2) The fact of being bilateral, although Bartels"* reports a bilateral
dislocation of the head of the radius in a boy, acquired by pushing a

110 ORIGINAL ARTICLES.

heavy cart, and Pungaud'* reports an instance in which both radial
heads were dislocated by violent parturition.
C3) Concurrence of other deformities.

(4) Inheritance.

(5) Pronounced bone changes; but bone fusion, similar to that
occurring in the cases of dislocations, is reported without dislocation
by Drenkhahn'^ (one case), JoachimstaP® (three cases), Kiimmell"
(three cases, one bilateral), and Hamilton** (one case, bilateral.)

(6) Greater mobility than to be expected in acquired dislocation.

Upon applying these arguments to the 51 cases reported as con-
genital, it is seen that the congenital character of some is more or less
in doubt, judging by the evidence presented. In many of these cases,
however, the reports, if full, would probably confirm the assertions
of the respective authors, and, on account of the difficulty of making
a satisfactory standard for discrimination, and on account of the large
number of the cases that are congenital beyond reasonable doubt, it
has been thought wise to include all the 51 reported cases in compiling
the summary.

(3) Etiology.

Blumenthal refers the lesion to the pronated position of the fetal
elbow in human gestation and the special exposure of the head of the
radius in this position to injury dependent upon deficient liquor amnii.
This would account for the usual limitation of supination in these cases,
as well as in the cases of congenital interference with supination with-
out luxation.*®

Ambard^^ refers his case (Number 46) to congenital syphilis, and
Bottomley** reports two cases of Cotton's in which congenital syphilis
produced acquired dislocation of the head of the radius similar to the
congenital dislocations.

Heredity appears to be operative in Pye-Smith's, Abbott's, and
Blumenthal's cases (Numbers 9, 33, 34, 35, 36, 37, 38, 39, and 44).
In the seven cases of Abbott's, which cover four generations in one
family, the individual transmitting the lesion was only once himself or
herself subject to it.

Hamilton** classifies the theories of causation of congenital dislo-
cations in general as follows :

(i) Physiological: original or developmental defect.

(2) Pathological: contraction, paralysis, lax ligaments, hydrathro-
sis, or some other diseased condition of the joint.

(4) Treatment.

Four operated cases are reported:

(i) Complete excision of the elbow in Mitscherlich's case (Number
7) by Langenbeck, for relief of great limitation of flexion and perma-
nent supination, in a double forward dislocation. The result was not
observed, as the patient died shortly after operation.

CONGENITAL LUXATION OF RADIAL HEAD 111

(2) Excision of radial head only and manipulations, in Bessel-
Hagen's case (Number 26) of backward dislocation, for relief of
pronated and semiflexed position and limitation of all motions. Result,
one year after operation: normal motions.

(3) Excision of radial head and distal end of ulna, and osteotomy of
shaft of radius, in Bonnenberg*s case (Number i) of forward luxa-
tion, for limited extension and permanent supination. The lower end
of the ulna was excised because rotary motion was found to be impos-
sible without this excision. The shaft of the radius was divided to
straighten the arm. The result was free extension and flexion and
a position of pronation, but no rotary motion.

(4) Excision of radial heads and manipulations, in LaFerte's
bilateral case (Number 50) of forward luxation, for permanent exten-
sion and pronation. Result two years after operation : passive but no
active flexion, and no supination.

In one of the cases reported by Bottomley,** of acquired backward
luxation but similar to the congenital type, excision of the heads of the
radii greatly improved the mobility, which had been restricted in all
directions.

Thus in two of the three cases of congenital luxation in which the
head of the radius was excised, free active flexion and extension was
obtained, and in the third case passive flexion was obtained. Rotation,
however, was restored to only one of these three cases, though in one
of the other two the preferable position of pronation was substituted
for that of supination.

In none of the operated cases was there bone fusion, complicating
the luxation.

v.— CONCLUSIONS.

Nearly two-thirds of the cases of congenital luxation of the head
of the radius are male.

Equally common on the right and left sides.

The commonest direction of luxation is backward; forward luxa-
tions nearly as common ; outward luxations only once in eight.

In nearly all of the combined cases, mobility is more or less
restricted ; but in half the outward luxations, mobility is free. Supina-
tion is the motion most often limited ; extension, next most often. In
backward luxations, flexion is the motion most often free; while in
forward luxations, extension is the motion most often free.

Elongation of the proximal end of the radius is present in three-
quarters of the cases, and is about equally frequent in the luxations
in the diflFerent directions.

Bone fusion of the upper parts of radius and ulna present in one
third of the cases. In all the cases with fusion, there is no or almost
no rotary motion, and the forearm is pronated or semipronated.

In nearly half of the cases, there is some other deformity, oftenest
partial deficiency of ulna or radius.

Congenital luxation of the head of the radius is very rare.

112 ORIGINAL ARTICLES

The congenital character of some of the fifty-one reported cases is
open to doubt.

The factors to be considered in etiology are the special embryology
of the elbow, congenital syphilis, heredity, and the conditions leading
to congenital luxations in general.

Excision of the head of the radius is indicated by considerable
restriction of flexion or extension in uncomplicated cases; doubtful,
in cases with only rotary motion restricted; probably cc«itraindicated,
in cases with practically free flexion and extension but permanent
pronation and bone fusion.

REFERENCES.

* Powers, C. A. : The Journal of the American Medical Association, 1903, XLI,

page 165.
' Blumenthal, M. : Zcitschr. f. orthop. Chir., 1904, XII, i u. 2 Heft, S. 181.
' Bonneberg : Zcitschr. f. orthop. Chir., 1893, II, page 376.

* Abbott, F. C. : "Transactions of the Pathological Society of London," 1891-2,

XLIII, page 129. Also: Lancet, 1892, page 800.

* Giirlt : Beitrdge zur Vcrgleich. path. Anat. der Gelenkrankheiten, 1853, page

317, Dupuytren's case. Through Bonnenberg.
Stimson, L. A. : "Treatise on Dislocations," 1888, page 349, same (Dupuy-
tren's) case.

*Malgaigne, J. F. : Die Knochen-briiche u. Verrenkungen, 1856, Band II, page
631, from Dupuytren's oral report. Through Bonnenberg.

"Servier: Gas. Hebdom. de Med. et de Chir., 1872, IX (second series), page
214.

"Herskovitz, L. : Wien. med. Presse, 1888, XXIX, page 217. Through Bon-
nenberg.

'Humphrey: Med. Chir. "Transactions," XLV, page 296. Through Stimson.

'" Mitscherlich: Archiv. f. klin. Chir., 1865, VI, page 218. Through Stimson.

" Allen : Glasgow Medical Journal, 1880, XIV, page 44. Through Stimson.

"Pye-Smith: Lancet, 1883, II, page 993. Through Stimson.

*' Phillips : British Medical Journal, I, page 773. Through Stimson.

"Heele: Lancet, 1886, II, page 249. Through Stimson.

" Machenhauer : Centralblatt f. Chir., XIX, Nr. 13. Through Bonnenberg.

"Adams, R. : "The Cyclopedia of Anatomy and Physiology," 1839, H, page 75.
(Powers.)
Also: Dublin Journal of Medical Science, Volume XVII. Through Bonnen-
berg.

" Deville, A. : Bui. de la Soc. Anatom. de Paris, 1849, XXIV, page 153. Through
Bonnenberg.

"Senftleben: Archiv. f. path. Anat. von Virchotc, 1869. XLV, page 303.
Through Bonnenberg.

'•■ Cruveilhier, J. : "Traite d'Anat. Path. Generale," 1849, page 479. Through
Bonnenberg.

*® Bessel-Hagen, F. : Ueber Knochcn u. Gelenkanomalien, Laugcnbeck's Archiv.
f. klin. Chir., 1891, XLI, page 420. Through Bonnenberg.

" Smith, R. W. : Dublin Quarterly Journal of Medical Science, 1850, X. Through
Bonnenberg.

*' Smith, R. W. : Dublin Quarterly Journal Medical Science, 1852, XII, page 208.
Also: Proceedings of the Pathological Society of Dublin, 1841-50, I, part 2.
page 185.

LABOR DURING SECOND STAGE. 113

"•Toppich: "Beitrag zur Kenntniss der angeborenen Luxationen des Capitellum
Radii," 1888. Through Bonnenberg.

••Leisrink: Deutsch. Zeitschr, f. Chir., 1873-4, IV, page 16. Through Bonnen-
berg.

"Voigt: Wagner's Archiv. f. Heilkunde, 1863, IV, Seite 26. Through Bon-
nenberg.

*• Schmid : Zeitschr. f. orthoped, Chir., 1893, Band. II. Through Blumenthal.

" Ambard: Rev. d'Orthop., 1901, II (second series), page 173, Through Powers.

*• Bergtold, W. H. : Annals of Surgery, 1891, XIV, page 370. Through Powers.

*• Hamilton : 'Tractures and Dislocations," Philadelphia, 1880, sixth American
edition, page 888.

••Guerin: "Recherches sur les Luxations Congenitales," Paris, 1841. Through
Hamilton.

•* Present article.

" Stimson, L. A. : "Fractures and Dislocations," 1900, third edition, page 463.

** Kronlein : Deutsche Chirurgie, XXVI, page 82.

** Bradford and Lovett : "Orthopedic Surgery," New York, 1905, third edition,
page 479-

"Bartels: Archir. f. klin. Chir,, 1874, XVI, page 643. Through Stimson.

•• Pungaud : "Diet. Encycloped. des Sc. Med.," page 606. Through Stimson.

" Drer>khahn : Zeitschr. f. orthop, Chir., 1903, II. Through Blumenthal.

" Joachimstal : Die angeborenen Verbildungen der obern Extremitdten, 1900,
Seite 17. Through Blumenthal.

* Kiimmell : Die Missbildungen der Extremitdten, Biblioth. med., Band. III.
Through Blumenthal.

**Drenkhahn: Deut. milit'drdrstl. Zeitschr., 1905, Heft 6. Abstract Deut. med.
IVochenschr., 1905, July 6.

** Discussion of Powers* paper.

** Quoted by E. M. Moore, in "Reference Handbook of the Medical Sciences,"
Philadelphia, 1886, II, page 485.

" Riss, Raymond : "Die angelborene Luxation des Radius, Franzosische Disser-
tationen," Paris, 1902. Abstract in Centraiblatt f. Gynak., 1903, 38, page
1 150.

" Hamilton S : "Case of Congenital Synostosis of Both Upper Radio-Uluar Ar-
ticulations," British Medical Journal, November 18, 1905, Number 2342,
page 1327.

CONDUCT OF LABOR DURING THE SECOND STAGE.*

By WILLIAM H. .MORLEV, Ph. B.. .M. D., Ann Arbor, Michigan.

DBMONSntATOK OF OBSTBTRICS AND GVNBCOLOGV IN THB UNIVBRSITY OF MICHIGAN

An apology is due to members of the Society for bringing this
hackneyed subject to your notice, but my recent experience and the
vast amount of material at my command during two years abroad may
to some extent mitigate my extreme audacity in presenting this theme
for your consideration.

It is needless to tell you, but nevertheless important to define at the
outset the various stages of labor. Labor is arbitrarily, and for matter
of convenience, divided into three stages. The first dates from the
time the parturient commences to have labor pains until the cervix

♦Read before the Washten.aw County (Ann Arbor) Medical Society.

114 ORIGINAL ARTICLES.

is fully dilated. This condition of full dilatation is determined when
the patient begins to bear down. The second stage extends from full
dilatation of the os to birth of the child, and the third and last stage
from delivery of the child until the birth of the placenta and mem-
branes. In the first stage the pains may be so severe as to compel the
parturient to take her bed, but as a rule she is up and about. She
should, however, be put to bed soon after the membranes rupture, or
at the beginning of the bearing-down pains. This is especially impor-
tant in multipara as the second stage is usually of short duration ; often
lasting but five or ten minutes from complete dilatation of the cervix
to birth of the fetus.

I take it for granted that you have had your patient under sur-
veillance for some months previous to the beginning of the first stage,
and have made all necessary arrangements for the confinement. The
external examination, diagnosis of presentation and position, clipping
of vulval hair, aseptic preparation of external genitalia, dressings,
et cetera, have all been made. As the second stage is short in multipara,
it is well during the first stage to have the bed in readiness for recep-
tion of the parturient, and it is about its preparation that I wish next
to speak.

Preparation of the Bed, — ^A high iron bed is the best, but as often
occurs in private practice, the physician may be compelled to use the
low double bed. In either case its preparation is the same. The
accoucheur stands, or is seated at the left side. This fact should be
borne in mind when the bed and accessories are made ready for the
confinement. A rubber sheet of sufficient length and width should be
placed to cover the entire mattress. Over this an ordinary sheet.
Then a second rubber sheet of sufficient size to cover the middle third
of the bed and on top of this latter another sheet. These two latter,
that is, the rubber and the muslin sheet, should be so arranged as to
allow easy removal after completement of the third stage. The puer-
peral patient will then recline upon the large rubber and muslin sheet
mentioned above. In the bed thus prepared with its double layer of
rubber and muslin sheets, the parturient is placed, preferably on her
left side. Underneath her buttocks, which are brought as far as pos-
sible to the left edge of the bed, may be placed a Kelly pad, with the
apron extending over the edge into a bucket or pan, or what I per-
sonally prefer, a sterile pad of gauze and cotton placed under the
buttocks to receive whatever discharge may come from the vulva
during the second stage. To prevent contamination from the hips of
the patient, l^gings, which have been previously sterilized, are drawn
on and tied high up on the hips. The buttocks are covered with a
sterile sheet, and another is placed on the bed in front of the posterior
buttock.

Examination During the Second Stage. — ^Vaginal examinations,
except in rare cases, are to be condemned. External abdominal exam-
ination between pains to denote progress in descent, or the extent of

LABOR DURING SECOND STAGE. 116

engagement of fetal head, can be made as often as. necessary. I

Control of fetal activity by auscultation of fetal heart from time to
time is also a good procedure. But constant and repeated vaginal
examinations cannot be too strongly deprecated. The great risk of
.infection, and the small amount of additional information to be gained,
do not, in most cases, warrant such a drastic procedure.

Delivery. — When the vulva begins to gape or the perineum com-
mences to bulge, it is time for the accoucheur to disinfect his hands
and arms with soap and water, and then with bichloride. A long-sleeved '
gown and rubber gloves, both previously sterilized, are put on. Then
the sterile sheet is placed over the buttocks, and another on the bed in
front of the posterior buttock. It is seen that the parturient is on her
side, preferably the left, in a modified Sims position with her buttocks
near the left side of the bed. On a table near-by covered with a sterile
sheet are placed two sterile basins, one containing sterile water, and one
bichloride (one to two thousand). In both solutions are placed small
pledgets of sterile cotton. The table should also contain a basin with
tape for cord, scissors, and a catheter, all of which have been previously
sterilized. Instruments for perineal repair, obstetrical forceps, et cetera,
are boiled and kept in readiness. A blanket, or preferably a padded
box, over which a sterile bag with purse string suture is drawn, is put
between the knees of the patient. The left hand of the physician is
placed between the thighs of the parturient and brought around in such
a way as to cover the vulva. The right hand is free to wipe away
fecal matter discharged from the rectum with the pledgets of cotton
soaked in bichloride or sterile water, and to protect the perineum
during the pains. In this way the accoucheur has the fetal head and
perineum under complete control.

Use of an Anesthetic. — The question naturally arises, shall an anes-
thetic be employed ? In few cases, confinement may take place without
anesthesia. It is better both for mother and child not to administer
an anesthetic during the first stage. It often becomes necessary, how-
ever, in the second stage to give the parturient a few whiffs of chloro-
form to ease the pain, and at the same time save the perineum. Do
not slug your patients with chloroform. It is not necessary. It will
often unnecessarily prolong labor, and prevent later contractions of the
uterus. When a pain starts a few drops of chloroform on an Esmarch
inhaler will prove sufficient, and the cone should be removed at the
completion of the pain. A small amount of the anesthetic given
synchronous with pains will have the desired effect. There is little to
be said in the choice of an anesthetic. Qiloroform has, since its
discovery in 1847, by Sir James Simpson, been considered the ideal
lying-in-room anesthetic. Recent investigations with cocaine injected
intraspinously, with scopolamine, and other local anesthetics, have
shown some good results, and much is claimed by their adherents.
The results are too meager, however, to allow them to supplant chloro-
form.

116 ORIGINAL ARTICLES.

Protection of the Perineum, — As was mentioned above, the par-
turient is placed on her left side in a semiprone, or a modified Sims
position, with her buttocks near the left edge of the bed. The thighs
are held apart with the padded box, over which a sterile bag has been
drawn. The obstetrician stands with his left side against the edge
of the bed. His left arm is put around between the thighs, so that
the left hand may easily cover the vulva and control the fetal head.
The right hand is free to protect the perineum, and keep the parts
cleanly and aseptic with the pledgets of cotton, dipped alternately in
sterile water and bichloride solution. At the commencement of a
pain the left hand allows the head to slowly advance upon the already
somewhat distended perineum. The right hand, upon whose palmar
surface is placed a pledget of cotton wet with bichloride, is so placed
that the thumb and first finger span the fourchette. The perineum
is grasped on either side and slightly folded. As the head advances,
controlled by the left hand, the perineum is allowed to gradually receive
the force of the advancing head, so that before completion of the pain
the perineum has received the full impact of the head as rapidly or as
slowly as the physician desires. This can be repeated until it is thought
the perineum is fully dilated. I have by this method held the head
back with my left hand, when removal would have allowed the head
to slip over the perineum, which I did not deem fully stretched. When,
however, the perineum is fully dilated and extension has taken place
to such a degree that the forehead is visible at the fourchette, the
tension of the left hand between a pain be gradually relieved, and
birth of the head is allowed to take place. This is done in the follow-
ing way : the occiput is well out from under the arch of the pubes, and
the left hand gradually brings about increased extension of the head
by light traction on the brow. The right hand, whose thumb and
forefinger rim the fourchette, presses lightly but firmly on the perineum
and follows it down over the brow, face, and chin. External rotation,
or restitution, immediately takes place.

Cord About the Neck. — Examination is at once made to see if the
cord is about the neck. When such is the case it is at once reduced
by slight traction, and slipped over the head. It may be necessary to
clamp the cord when reduction is impossible. But these are rare
instances, as it is only in cases where the cord is unusually long that
it becomes wound around the neck, and from its increased length is
easily reducible.

Delivery of Shoulders, — As soon as the head is born the patient is
placed in the dorsal position. The head is grasped with both hands in
such a way that the palmar surfaces lie next to the lateral surfaces
of the head, and just anterior to the parietal bones. Slight pressure
is made downward and backward, until the anterior shoulder appears
well out from under the arch of the pubes. The head is then lifted
upward to allow the posterior shoulder to glide over the perineum.
Delivery of the body usually follows rapidly, but to prevent tear of

LABOR DURING SECOND STAGE. 117

the perineum the hands should still be kept on the head. In addition
the forefingers are lightly inserted in the child's axillae, and tjhe fetus
carried upward and forward over the mother's abdomen. In this way
the child follows the curve of Carus and its weight is not allowed to
tear the already greatly distended perineum. Care should be taken
not to use traction with the forefingers which have been placed in the
child's axillae. Stretching of the brachial plexus, or fracture of an
arm may result. The tension should be on the head, but to prevent
too great tension and the slipping of the hands from the head, the
forefingers are placed in the axillae. •

Ligation of the Cord. — The child is held upward by the lower limbs
and a parental slap made on the buttock to expel any mucus that
may lodge in the posterior pharynx and upper respiratory passages.
A vigorous lusty cry will denote that the trachea is clear. The child
is then placed on its right side close enough to the mother to prevent
traction on the cord. The cord is grasped and pulsation controlled.
As long, as the cord pulsates, it is not tied. When pulsation stops, a
narrow tape is passed around the cord about seven centimeters from
the child's body, and securely tied. Another is similarly placed, and
the cord ligated on the maternal side about three centimeters from the
first ligation. The cord is then laid in the palmar surface of the left
hand in such a way that the hand is interposed between the child's
abdomen and the ligatures. The cord is cut, all bleeding stopped, and
the child handed to the nurse.

A bed pan is placed under the patient's hips for reception of the
after-birth. The uterus is held by the hand of an assistant or nurse
to prevent its relaxation, and the third stage begins.

Use of Ergot. — So much has been written about the use of ergot
in the second stage, or at its completion, that I cannot refrain from
saying a few words on this point. Such a practice need only be men-
tioned to be most severely condemned. First, it is never indicated, as
slight massage of the fundus uteri will control any slight hemorrhage
in most cases. In uncontrollable hemorrhage, first remove the after-
birth by Crede's method, then give your ergot. Secondly, ergot
administered in the second stage will cause the uterus to contract
down upon the placenta and membranes, and cause their retention,
whole, or in part. I never prescribe ergot in the third stage unless
indicated, and am not a firm believer in its employment as a prophy-
lactic.

Repair of Perineum. — This properly belongs to the third stage, but,
should a tear occur, it may be well to pass the silkwormgut sutures at
the end of the second stage before the patient comes out from under
the anesthesia. The ends can be held with hemostats and tied after
the placenta and membranes are born. This does away with a second
anesthetic. Personally I prefer to let patient out and then repair any
tear at end of the third stage. A few whiflFs of chloroform are gen-
erallv sufficient.

118 ORIGINAL ARTICLES.

Such in brief is the method I have adopted in the conduct of labor
in the second stage. I do not claim any originality, do not believe I
have invented anything new. Having seen a good many different
obstetricians, and studied their methods, I have only taken what I
considered to be their best points to form one of my own. This I
have endeavored to bring to your notice this evening. Just one point
more ; do not forget that labor in most cases is a normal, physiological
process, and any unnecessary meddling may transfer it from the
domain of physiology to the realms of pathology. DO NOT DO IT!

REMARKS ON LA GRIPPE.
By JOHN S. CAULKINS, M.D., Thornville, Michigan.

Personal subjection to la grippe affords the most certain means of
obtaining a complete and intimate knowledge of the nature and results
of the disease, but the writer has not l^een permitted the opportunity
of study from the standpoint of patient, and can therefore only record
what has been observed in practice.

Description of the Disease. — It is difficult to classify Russian influ-
enza under any name that will imply the nature of the disease. The
nearest approach possible is to call it a catarrhal fever, but that scarcely
covers the ground, for many cases — perhaps a third of the total — show
very slight catarrhal symptoms. We might almost say there are two
distinct forms of la grippe — the catarrhal and the noncatarrhal. In the
first there is cough, congestion of the mucous membranes of the lungs,
throat and head, together with all the symptoms of a severe cold. The
other is a break-bone fever without the catarrh. The two have some
features in common, the fever in both being high, and the pain in head
and back, between^the hips, intense.

Tliermometry of the Disease. — Perhaps there is no other affection
in which the fever runs higher, not excepting malignant scarlet fever.
It is a scorching, burning fever. It is not so high now as formerly,
when it was common to record 104°, in cases of vigorous, strong boys
105° being noted, and in a few instances even registering above that
high point. However, seldom will much more than 103° be observed.
No low temperatures were found by me in typical unmixed cases, and
r think there are none, although this statement may be criticized in the
discussion of this paper. Some may say, perhaps all may unite in
saying, that, any grade of fever may characterize the malady, but I
have expressed my belief, and when every source of error is eliminated
I think the statement will be found correct. An epidemic of gigantic
proportions necessarily contemplates a great number of other diseases,
among which may be mentioned common influenza, which is always
endemic if not epidemic, and can only be discriminated from la grippe
by its milder type, the temperature being low. Here would be one,
and possibly the main, source of error. Another would lie in not
accurately observing the dividing line between the temperatures of la

REMARKS ON LA GRIPPE. 119

grippe and its numerous sequels. What renders my opinion probable
is the fact that every disease has its own thermometry from which it
does not vary much. This point is sometimes invaluable in differential
diagnosis. Who ever saw a low temperature in measles or scarlet
fever, or a very high one in rotheln?

Duration of the Disease, — La grippe, according to my observation,
lasts three days. If the attack has its inception on Monday morning
the patient will be free from fever on Thursday morning. Of course
I do not include relapses or sequels. These are not la grippe, they are
conditions that succeed it.

Complications, Relapses and Sequels, — Pneumonia has not been
observed as a complication by me, but it has been met as a sequel.
Bronchitis is a frequent complication, so are congestion of the lungs
and tonsillitis. It is doubtful if there is any real relapse of la grippe.
I should as soon look for a relapse of measles. The sequels of the
disease are many, some immediate and some remote. The immediate
in the order of gravity are pneumonia, nervous prostration, bronchitis,
and neuralgia. Among the remote, consumption has caused death in
some who had la grippe two years previously. In another class of
cases the mischief that was done by la grippe can only be described by
saying that the constitutions of the subjects were wrecked by the
disease.

Tlie Cause. — For hundreds of years there has been great speculation
over the cause of this disease. Influenza is an Italian word that has
been used in the English language until it is naturalized and means
simply influence. The influence of what? When the world believed
in astrology, it was thought to be rained down by certain malign stars
in conjunction or apposition, or whatever the phraseology. That
superstition outgrown, it was believed to be caused by some occult
telluric influence. This idea has been promulgated in my time not
only with regard to influenza but Asiatic cholera as well. The Germans
adopted the name for the disease. They called it the Nordische or
Russiche influentz. The belief in an influence was natural enough at
that time. The spectacle of so many falling sick at once, suggested
the idea of the disease being sent by some power inimical to the human
race. The French name suggested something akin to the same idea;
as if some invisible monster had suddenly grasped its helpless victim
in its talons.

La grippe is an essential fever, and like the rest of its class can have
but one way of spreading, and that is by the reception into the circula-
tion of its own contagium virum, the living microbe or fungus, which
causes the sharp and active fermentation in the blood, so characteristic
of the disease. It would be more correct to say, which is the disease.
The ptomaines generated during this fermentation must be peculiarly
poisonous, for the extreme prostration, lassitude and pain which mark
the disease are out of all relative proportion to the catarrhal symptoms
and must be caused by these poisons. The microbe of la grippe is not

120 ORIGINAL ARTICLES.

yet identified, or at least observers who claim to have discovered it do
not agree in its description. Pfeiffer, the son-in-law of Koch, is the
latest claimant, and the confirmation of his alleged discovery is looked
for with interest, but if his claim is not confirmed, nor even that of any
other observer, we may rest assured that the microbe is in waiting to
be discovered.

Pfeiflfer is connected with the Berlin Institute for Contagious Dis-
eases. His conclusions are based on a careful study of thirty-one
cases of la grippe, six of them being postmortems. His microbe is a
minute rod or bacillus as thick as that of mouse septicemia and half as
long. There is some difficulty about culture and staining, and this has
misled other observers. PfeiflFer believes that other observers have
seen the same bacillus but have described it as a micrococcus because
it takes the stain at the ends. Kitasato has seen and described the
bacillus, agreeing essentially with Pfeiffer. The microbic and con-
tagious nature of the disease is admitted, but some work is needed to
learn just how the contagium virum is conveyed from one to another.
In all probability it is in the breath of the patient, and perhaps in the
secretion of the skin.

Treatment, — More than three-quarters of the cases of la grippe are
treated at home in a variety of ways. A favorite method of treatment
is to take a dose of pills and^drink all the cider, made strong with red
pepper, one can hold. The other quarter, or less, that the doctor sees
are mostly complications and sequels and are to be treated symptomat-
ically. There is no specific for the disease. It is a good plan, if the
person is seen during the attack, to give a cathartic — say a dose of
compound cathartic pills. The operation will materially relieve the
intense pain in the head, and awaiting that, a dose or two of acetanilid
will afford much relief. We ought, however, to select our cases for
this treatment. The effect is too depressant sometimes for safety.
Now and then a patient will sweat so profusely that it is really alarm-
ing. We should be very careful with acetanilid in la grippe. Still, I
have given it to small children and once to a man eighty-two years of
age, with excellent effect. Antipyrine. which was so extensively used
two years ago, seems to have dropped out of focus. Beyond a doubt
much harm has been done with that drug. That class of remedies, in
such a prostrating disease as la grippe, ought to be used with great
caution. After the bowels are evacuated opiates are to be preferred to
them if the pain in head and back continues. Quinine is not a specific
in la grippe. It neither shortens its course nor does it afford any -relief
so far as 1 have observed.

Notwithstanding treatment the malady has its course to run and the
function of the doctor is to see that the course runs normally and to
obviate, if possible, any threatened mischief. Avoidance of all exposure
for a week after the disease subsides is of the utmost benefit to the
patient. It -is carelessness in this particular that makes work for the
doctor.

WASHTENAW COUNTY MEDICAL SOCIETY. 121

TRANSACTIONS.

WASHTENAW COUNTY MEDICAL SOCIETY.

REGULAR MEETING, ANN ARBOR, DECEMBER 14. iQ^S-
The President, JOHN A. WESSINGER. M. D.. in the Chair.
Reported by JOHN WILLIAM KEATING. M. D.. Secretary.

REPORTS OF CASES.
AN UNUSUAL CASE OF DYSMENORRHEA.

Doctor James B. Wallace: A single lady, aged twenty-one
years, living at home, came to me March 18, 1905, complaining of
severe attacks of dysmenorrhea. She is the second daughter in a family
of four girls. Her mother, now aged forty-five, w-as troubled with
severe menstrual pains when a girl and attributed the patient's affection
to an hereditary influence. The patient's sisters have no more pain at
the menstrual periods than is considered normal. The jnother is a
healthy woman and her confinements were normal and easy. The
family are all in good health except the patient, and she has never
experienced any trouble except at the menstrual periods, and the fact
that she is subject to a very obstinate constipation.

The patient has had the ordinary diseases of childhood, and no
other sickness nor disease. She was regarded to be perfectly well up
to the age when she would ordinarily begin to menstruate. About the
time she was thirteen or fourteen years of age her mother noticed that
she was nervous and feverish, and oftentimes choreic. This she attrib-
uted to the approaching catamenia and did not pay much attention to it.
The nervous disturbances did not disappear although the mother thinks
they did not increase as time went on. Menstruation was not estab-
lished, however, until the patient was seventeen years old, and at that
time she was almost in convulsions from the pain. The girl had no
medical treatment during the years of approaching maturity, except
some patent nerve nostrum, Lydia Pinkham's vegetable compound, and
Porter's pain king.

After the menstrual function was established, the patient felt better,
except a few days before and during the menstrual week. Her nervous-
ness and apprehension did not abate, but she began to await the dreaded
period with feelings approaching hysteria. The pain just before the
flow began was so severe that for a few months before the patient came
under my observation, she had gone into convulsions at those times.
She was quite irregular, sometimes going seven to eight weeks, and at
other times menstruating as often as every two or three weeks.

The period in February, 1905, was the worst she ever had, and the
mother told me that she had much more severe pain than any woman
she had ever seen in labor. The reason she had never had treatment
for her trouble was an implicit faith in patent medicines on the part of

122 ORIGINAL ARTICLES.

her mother and a somewhat exaggerated dread of exposure on her part.
On March i8, 1905, the mother came to consult me about her but
dtd not bring the patient along. I obtained the facts of this history as
I have given them, from her at that time. I plainly told the mother
that she must bring the patient and be prepared to have her examined
if need be, before I could tell her the cause of her trouble. Several
days later they came to my office. The girl was a well-nourished, and
healthy-looking lass, and did not show the signs of the nervous disturb-
ances through which she had gone. A careful and extended physical
examination showed that there was nothing wrong with any of the
organs of the body except the site of the trouble, plus the chronic consti-
pation, and a peculiar drawing or bearing down feeling during the act
of defecation and sometimes also while passing urine. I then told the
mother that unquestionably there was some abnormal position of the
uterus and that I would make an examination. The patient consented
and the cause of her trouble was soon apparent. The nymphae were
very long but as the girl was scrupulously cleanly there were no irri-
tants IcKjged there. The hymen was normal but very tight, and I found
much difficulty to introduce the finger even through the hymen without
producing much pain. Finally this was eccomplished and I found the
vagina apparently smaller than the hymen. It appeared so small that
I had to abandon the use of the finger and make exploration with the
sound. The vagina was of normal depth and I could easily touch the
OS uteri with the sound. While attempting to withdraw the sound
I observed that the point caught upon something which I could not
make out. Examination per rectum showed a retroflexion of the third
degree. A speculum could not be introduced into the vagina so I
tried a branching ear speculum which showed the cause of the trouble.
Just inside the hymen was a septum extending from the anterior to the
posterior wall, the whole length of the vagina and dividing it longitu-
dinally into two nearly equal parts. I advised its immediate removal.
This was agreed to, but the girl would not permit my bringing another
physician to give the anesthetic. The next day I went to the patient's
home, where I made ready, gave the anesthetic, and dilated the vagina.
I found that the os uteri was freely movable ; a sound could be passed
into it from either passage. The unusual part of this case consisted
in the part of the septum near the os uteri. For about one inch in
length, there was a wedge-shaped portion, — the base impinging against
the OS — the apex becoming continuous with the membranous septum.
This wedge-shaped portion was firm and contained muscular tissue.
I removed the septum, controlling the hemorrhage with spray of adre-
nalin; sewed up the wounds with chromacized catgut; replaced the
retroverted uterus: packed the vagina with gauze; catheterized the
bladder, and permitted the patient to come out from the anesthetic.
When awake she said she had no pain and felt all right. I called again
that night and there was no pain.

Patient recovered without suffering any inconvenience, her bowels

CLINICAL SOCIETY. 128

became regular, and on the morning of the ninth day afterward she
called her mother in alarm saying that the wound must have started to
bleed. The mother telephoned for me and I went out and found that
her period had come on anB she had begun to menstruate freely and
without a trace of pain for the first time in her life. That was in
March. Since then she has menstruated rcgularjy and has never had a
symptom of pain. The uterus has stayed in normal position and she

I has no more need for the nostrums she formerly imbibed.

That wedge-shaped septum formed a cup-pessary which tilted the
uterus backw^ard, and when the organ became turgent and distended"
with blood at the period, occluded the os, producing the pain and con-

I vulsions until the flux forced itself past the obstruction.

i The girl is strong and well and is not so much afraid of doctors ;

the mother is pleased, and has lost a very large part of her confidence in
patent medicines.

CLINICAL SOCIETY OF THE NEW YORK POLYCLINIC.

STATED MEETING, FEBRUARY 5, 1906.

The President, JOHN J. MacPHEE. M. D., in the Chair.
Reported by FREDERICK C. KELLER, M. D., Secretary.

READING OF PAPERS.
ACUTE PELVIC INFECTIONS,

I Doctor Joseph C. Taylor read a paper on the above subject. He

said, in part : It is but a few years since a woman's tubes and ovaries
were sacrificed by an operator lest a future laparotomy should be
required. Actuated by a sense of thoroughness, he deprived women
of the function of menstruation, which is interwoven with their mental
as well as physical life. It is better to conserve these organs, even if
elaborate and hazardous procedures must be adopted to accomplish this
end as well as to cure the patient. He did not advocate, however, the
carrying of conservatism in connection with special organs so far as
to endanger the constitutional condition of women. There is a broader
conservatism, which seeks to restore the general health of the patient,
even if special organs must be sacrificed to attain such an end. To
this end he made an appeal for early surgical interference in acute
diseases of the female organs. Conservative operations sometimes
may fail ; but even if they do, radical procedures must be adopted later
without added risk to the patient. On the other hand, it is impossible
to restore organs removed by radical work.

For many years it has been customary in most large hospitals to
treat patients suflfering from extension of gonorrheal inflammation to
the tubes by hot antiseptic douches or perhaps by tampons and an ice-

124 ORIGINAL ARTICLES.

bag externally over the lower abdominal region. When the acuteness
of the attack had somewhat subsided the tubes as well as the ovaries
were frequently swollen and engorged to such an extent as to be desig-
nated as tumors and removal was advised ; whereas, without apparent
mutilation, the inflammation might have been checked in the beginning
and the woman allowed to keep her organs, though somewhat damaged.
The conservative work to be attempted is mainly that of evacuating
the free pus in the culdesac when the operator is convinced by the
bulging of the wall of the posterior fornix that purulent exudate is
present in abundance. The gonococci, in an active state, after they
have gained entrance into the uterine cavity, cause a destruction of
the superficial cells, work their way into the deeper layers, and are the
cause of an immense amount of purulent exudate, destruction and
infiltration of the outer layers and edema of the deeper structures.
Unfortunately, after gonorrhea has once become well established within
the uterus, it invades by continuity of tissue the Fallopian tubes. The
inner surface of the uterus may become such an active seat of inflam;
mation in its deeper layers that the walls of the smaller vessels become
involved, as do the surrounding lympathics, and the normal structure
is almost entirely destroyed. The walls of the uterine cavity thus
become suppurating surfaces, which later become sclerotic, and this is
followed by a shrinking of the organ. This is frequently the case in
mixed infections.

If the tubes are opened and drained during the onset of the disease,
the woman may retain her organs, though somewhat damaged. The
operation is very simple, but it necessitates a thorough knowledge of
female pelvic anatomy and careful manipulation of special instruments.
An incision is made on the posterior surface of the cervix at the junc-
ture of the vaginal mucous membrane with the cervical, care being
taken to keep close to the cervix. A ^air of blunt-pointed scissors,
curved on the flat, seems best adapted for this purpose. When the
incision is made in the curve of the fornix, a painful scar is apt to
result, the nearer the rectum is approached the greater being the sensory
nerve supply. After incising the mucous membrane and retracting the
divided edges, a small amount of loose alveolar tissue is encountered
(most marked in women after the menopause). After incising this the
peritoneum is easily divided or punctured. With the forefingers the
opening can be enlarged. The uterosacral ligaments being pushed
outward by the palmar surfaces of the fingers and the intestines carried
out of the way by means of the Trendelenberg position and held there
by pads, the tubes are easily brought into view by means of the proper
instruments for retraction. If this procedure is adopted in the very
early stages, as it should be, the tube will be found reddened, swollen,
and with a tendency to sink into the culdesac. It should be grasped
with a pair of blunt forceps, such as those of the modified Hunter type,
on the dorsal surface, and pulled into the opening. It should be remem-
bered that the tube, like the ovary, except at its uterine extremity, is

CLINICAL SOCIETY. 125

fed by small ascending branches from the ovarian artery, which enter
the structure from the lower surface; consequently, when an incision
is made it should be on the opposite side. Care should be taken to
keep the intestines out of the way by means of pads, the tubes being
incised along the outer two-thirds of the upper border. The contents
should then be evacuated and the entire surface thoroughly swabbed
with five-per-cent iodoform gauze. At first there will be considerable
oozing of blood, which gradually subsides, no main vessel having been
cut. A small strip of iodoform gauze should then be placed over the
raw surface, an end protruding into the vagina. The first eflFect of
this treatment is to reduce the interstitial cellular infiltration, as it is
a well-known fact that the gonococcus does not thrive well on exposed
surfaces, its natural abode being in the deep recesses of compound
racemose glands. The gauze may be removed from the culdesac in
from five to six days. This may be done with safety after such a
period, as the life of the gonococcus at best is very short, except in
racemose glands and closed sacs.

REPORTS OF* CASES.

FRACTURE OF THE ULNA DURING MASSAGE FOLLOWING OPERATION
FOR COLLESr FRACTURE.

Doctor Frederick C. Keller : I wish to show this patient. After
the removal of the splint her arm was being massaged when the ulna
snapped at a point several inches above the original site of fracture.
This occurred six or eight weeks after the operation, and could be
attributed only to some inherent disease of the bone.

DISCUSSION.

Doctor Joseph C. Robertson : I have put up from two hundred
to three hundred cases of Colles' fractures during the past eight years,
and until two years ago have applied a posterior splint, the arm being
semiflexed in a stiflf position. This gave far from perfect results in
eight out of ten cases. A careful study of these cases has convinced
me that the best results are obtained by applying a posterior splint
from the hand to the elbow, keeping the arm perfectly straight, and
putting a pad of cotton under the wrist. As a result there is no sharp
protrusion of the ulna at the elbow, as often occurs when the hand is
put up anteflexed.

Doctor John A. Bodine: Something was wrong with the com-
position of the bones of this patient, as ulnas do not snap from massage.
The bones were probably chalky. As to Doctor Robertson's experience
with Colles' fractures, I think that each surgeon favors the line of
treatment with which he, personally, has obtained the best results. I
think a posterior splint more practical, for the reason that the posterior
surface of the arm is a straight surface, and has no cutaneous nerves
and no return blood supply. If a rigid anterior splint is applied to the
front of the arm, edema is caused by obstruction of the circulation.

126 ORIGINAL ARTICLES

INTUSSUSCEPTION.

Doctor Alexander Lyle: I desire to report a case of intussus-
ception occurring in a child seven and one-half months old. The
patient, well-nourished, healthy, active and breast-fed, had enjoyed
perfect health, with the exception of constipation, until the evening of
December i8, 1905, when he was suddenly seized with severe abdominal
pain, as evidenced by crying and flexion of the thighs upon the abdomen.
He was given a hot mustard footbath, and, internally, hot water with
gin and paregoric. His bowels had moved normally on the preceding
day, but not on the day of the attack. At i a. m. the child passed about
half an ounce of bloody mucus but no fecal matter. Pain was severe
and recurrent in character and at 6 a. m. on the 19th a physician was
summoned. He ordered half an ounce of castor oil. This failed to
produce an evacuation of the bowels. On the evening of the 19th he
ordered an enema (rectal) of glycerine and hot water. During the
night the mother noticed a sudden change in the child's condition and
thought it to be dying. She could not reach the physician, and in the
morning I was summoned. On reaching the house I found that the
physician had arrived and had given an enema of an ounce of castor
oil and one pint of warm water, the water returning with bloody mucus.

Hasty examination showed a state of collapse, a weak pulse that
could not be counted, a tense, rigid abdomen, and a rectal temperature
of 103° Fahienheit. A diagnosis of intussusception was made and
immediate operation advised as offering the only hope (and that a poor
one.)

' The child was immediately brought to the Polyclinic Hospital and
operated upon. No tumor could be mapped out, even after he had
been anesthetized. An incision was made in the right rectus muscle,
just below the umbilicus, the abdominal contents examined and' intus-
susception located in the ileocecal region. A firm, dense band of
adhesion anchored this portion of the intestine, necessitating a con-
siderable amount of work before it could be brought into the wound.
This was finally accomplished and the intussusception reduced. The
gut was not gangrenous and therefore was returned to the abdominal
cavity. A loop of small intestine w^as picked up and two drams of
saturated solution of magnesiurn sulphate was thrown into it by means
of a syringe, the needle of which was carried obliquely into the lumen,
the object being to evacuate the bowels as soon as possible. The
abdominal wound was then closed.

Following the operation the child's temperature rose to 103.5°
Fahrenheit, and remained so until i a. m. of the next day, when it
dropped gradually to 99.5° Fahrenheit, and did not rise above 100.8°
Fahrenheit at any time afterward. The pulse could not be counted
until the temperature had fallen to 101.8° Fahrenheit, when it was 160,
later falling to 118 or 120. The bowels moved five times during the
first twenty-four hours after the operation.

CLINICAL SOCIETY. 127

I would emphasize the point that valuable time must not be lost by
useless, or, more properly speaking, positively injurious and dangerous
medication. The sudden abdominal pain, followed by a discharge of
bloody mucus from the rectum, the recurrent attacks of pain and
absence of fecal exacuations indicate immediate operation. Gangrene
or extensive adhesions, or both, are produced by delay, and an intes-
tinal resection and circular enterorrhaphy will be necessary. An early
operation, on the contrary, enables the surgeon to early effect reduction.

DISCUSSION.

Doctor Bodine : One point should be emphasized in the diagnosis
of an inflammatory abdominal condition in a child, and that is the
expression of the face, which is always typical. Another aid is the
abdominal pain. I think it would have been impossible to have made
a differential diagnosis between this condition and appendicitis if it
had not been for the presence of the bloody mucus.

Doctor Maurice Packard : In cases of abdominal lesions in chil-
dren up to three years of age, the differential diagnosis between intus-
susception and strangulated hernia usually has to be made. The only
point in diagnosis especially pointing to intussusception is the bloody
mucus. A body temperature of 103° Fahrenheit, and a rapid pulse
are also significant, as the statement is made in many text-books that,
except in appendicitis and general peritonitis, the temperature and pulse
are normal and the abdomen relaxed. It has been my experience that
in intussusception children always have a high temperature and have
a pulse so rapid that it is almost impossible to count it. In cases of
intestinal obstruction the absence of stools and gas assists one in making
a differential diagnosis, as in intussusception only mucous and blood
pass from the bowels.

LARGE OVAR/AX CyS7\

Doctor Charles G. Child, Jr. : I removed this cyst from a patient
thirty-eight years of age. She has complained of pain for four or five
years, during which time she noticed the presence of a tumor, which
grew progressively larger. Examination revealed an enlargement
reaching to the umbilicus. It was impossible to palpate the appen-
dages on either side, and it was also impossible to determine on which
side the tumor originated. On account of the pain being on the right
side it was concluded that the tumor was of the right ovary, but at
the time of operation it was found to involve the ovary on the left side
and to have rotated the uterus. It firmly compressed the appendages
on the right side, which accounted for the pain on that side. A
transverse incision showed the cyst to be inherent in all directions to
the omentum and posterior peritoneum. A portion of it was free from
adhesions, and at this point the fluid contents were aspirated. The

128 ORIGINAL ABSTRACTS.

sac was then pulled out, with the intestines and omentum, and the
adhesions separated. The sac contained a dark, water-like fluid, which
is rather unusual, the contents of such a tumor usually being of a
yellow straw color.

ORIGINAL ABSTRACTS.

MEDICINE.

By GEORGE DOCK, A. M., M. D., D. Sc, Ann Arbor, Michigan.

PKOriSSOK OP MWDICINB IN THE UKIVBRSITT OF MICHIGAN.

AND

DAVID MURRAY COWIE, M. D., Ann Arbor, Michigan.

FIRST ASSISTANT IN MBDICINB IN THB UNIVERSITY OF MICHIGAN.

THE RHYTHMIC SOUNDS OF THE ALIMENTARY CANAL.

In a decidedly interesting description of a series of investigations into
the causes of the various sounds produced in the gastroenteric canal,
Cannon (Jama, January 20, 1906) concludes that stomach sounds are
best heard over the pyloric ring at the tip of the eighth rib. These
sounds are explosive in their character, loud, and correspond with the
rhythmical contraction of the pylorus, they occur about once in every
twenty seconds and are distinguished by auscultation with a stetho-
scope. Small intestine sounds can be differentiated from those of the
stomach and large intestine sounds by auscultation over the lower por-
tion of the abdomen. These sounds are best heard when the stomach is
empty, in the early morning, and particularly over the lower left
quadrant; the object of this position is to get as far away from the
active portion of the colon as possible. The sounds are soft, confused,
rolling, rising and falling in intensity, not rattling and explosive like
those of the stomach. They continue for four or five seconds, disap-
pear, and return again at intervals of seven or eight seconds, and persist
in the same location for indefinite periods of time.

The sounds of the large intestine present no periodicity, are easily
distinguished from the other sounds, and are heard over any portion of
the active colon, the ascending and transverse portions. The sounds
are very coarse and rumbling, with heavy gushes of gas from one seg-
ment to another. The intervals are longer, from fifteen to forty-five
seconds.

The author used, as a method of eliminating the personal equation,
a recording telephonic transmitter. The article should be read with
care, as it is impossible to do justice to it in a brief review. The sounds
are somewhat dependent upon the character of the food eaten, that is,
certain sounds can be better differentiated if certain substances are
eaten. d. m. c.

TREATMENT OF FRACTURE. 129

SURGERY.

Bv FRANK BANGHART WALKER, Ph. B., M. D., Detroit. Michigan.
rmowwMom op svmGBitT amd opbrativb surgbkt in the dbtkoit postgkaouatb school of MBDiaMi;

ADJUNCT FKOPUaOK OP OPBBATIYB SUKCBKT IN THB DBTKOIT COLLBGB OP MBOiaNB.

AND

CYRENUS GARRITT DARLING, M. D., Ann Arbor, Michigan.

CLINICAL PBOPBSaOK OP SUBOBBT IN THB VNIYBBSITT OP MICHIGAN.

THE MODERN TREATMENT OF FRACTURE.

Carl Beck, M. D., of New York (Medical Record, Volumel.XIX,
Number XII). It is quite refreshing to read an article with the above
title, in which the writer dares to advance new ideas and cut away from
some of the traditions which have long interfered with the scientific
treatment of fractures.

The Roentgen ray has not only become a valuable aid in diagnosis,
but compels much better resuhs in treatment. Injuries that were for-
merly treated as dislocations, sprains, contusions or distortions are now
known to be fractures, a glance through the fluoroscope revealing the
true condition.

Fractures without displacement, entering an articulation, may have
considerable effusion. Without knowing the condition the surgeon
would be strongly tempted to manipulate. A skiagraph would at once
show the condition and suggest the line of treatment. The writer
prefers a plaster-of-Paris dressing because it adapts itself to any part
of the body and offers no obstacle to the Roentgen rays.

The rules, that fragments must be reduced, and that, after proper
position has been attained fixation is in order, while simple, are fre-
quently violated.

The dogma that the soft tissues are the most important part of the
treatment of fractures, is dangerous. Repair must take place in the
bone, while the soft parts may be injured by imperfect reduction. With
perfect reduction joints and tendon-sheaths are at once set free and
remain so, unless immobilized for a long time.

A fracture is a wound in which union by first intention is desired ;
accurate coaptation of parts is therefore necessary. What was for-
merly regarded by many as bone callus was nothing but a displaced
borie fragment. The only way to insure the exact reposition is by
using the Roentgen ray. The practitioner must resort to this not only
for the good of his patient but for his own protection.

In old displacements of not more than two weeks standing refrac-
ture may be successfully performed under anesthesia. Old fractures
are to be opened and refractured with a thin broad chisel; in such
cases when there is great tendency to displacement suturing with bronze
wire is indicated. Periosteal shreds may become ossified and lead to
deformity. When the bone is treated by open operation these should
be carefully removed.

The patella offers a good example for technique of operation. It

130 ORIGINAL ABSTRACTS.

has little tendency to osseous regeneration. Effusion following frac-
ture tends to keep the fragments apart. Contraction of the muscles
tends to keep them separated, and soft tissues interpose to fill the gap.
The Roentgen ray shows that not in a single instance is reduction
perfect even under anesthesia. The only rational remedy is to open
the joint, remove the intervening structures, and accurately replace the
suture with catgut or bronze wire, according to conditions.

A number of histories are given to illustrate the points taken. The
views which he holds are summarized as follows:

( 1 ) The Roentgen method, in combination with the usual methods
of examination, determines the character of the suspected bone injury.

(2) If there be no bone injury, the proper treatment consists in
massage, followed by immobilization, a movable splint being prefer-
able for the latter purpose.

(3) If there is a fissure or fracture, followed by no displacement,
manipulations of the injured area must be avoided and immobilization
m the most comfortable position applied. As a rule, plaster-of-Paris
dressing answers the purpose best. After two or three weeks it must
be removed and massage begun. In about two weeks a splint of
plaster-of-Paris is applied, which the patient can take oflf and reapply.

(4) If there is any displacement, reduction must be applied at once.
This can be done under the control of the fluoroscope on a translucent
table, a plaster-of-Paris dressing being applied after reposition is per-
fect. This is a simple, short and cheap method. A more tedious, but
a safer way is to reduce the displacement under the guidance of a
skiagraph taken before. This will indicate in which direction the
efforts at reduction must be made, and how far. After a plaster-01-
Paris dressing, padded with cotton layers at its ends only, is applied,
the skiagraph is taken through it in order to ascertain whether reposi-
tion was complete. If it does not seem to be, the dressing must be
removed and another attempt at reposition made. If the process of
reduction meets with difficulties, an occurrence which can, as a rule,
be anticipated from the nature of the skiagraph, anesthesia should be
employed.

(5) In those cases, in which, on account of entanglement of the
fragments, extensive splinter formation, or similar complications, repo-
sition'even under anesthesia cannot be accomplished, the fragments
must be exposed by the scalpel and brought into apposition. If there
be no tendency to displacement, a plaster-of-Paris dressing will insure
immobilization. But if the fragments slip out easily, it is safer to
unite them with catgut, provided there is enough periosteum to be
utilized for that purpose. Otherwise it is best — especially if large
bones come into consideration — to keep them together with a bronze
wire suture. The sooner this is done the better it will be, because the
smaller are the changes taking place in the soft tissues. c. g. d.

BACTERIOLOGY OF PERITONITIS. 131

GYNECOLOGY.

By REUBEN PETERSON, A. B., M. D., Ann Arbor, Michigan.

ntOilllllK or GTMBCOLOGT AND OBSTBTKICS IN THE UNIYBKSITY OP MICHIGAN.

AND

CHRISTOPHER GREGG PARNALL, A. B.. M. D.. Ann Arbor, Michigan.

FIKST ASSISTANT IN GTNKOLOOT AND OBBTBTRICS IN THE UNIYnSfTT OP MICIIIOAN.

RECENT RESEARCHES INTO THE BACTERIOLOGY OF
PERITONITIS IN RELATION TO PELVIC SURGERY.

Sargent {Journal of Obstetrics <md Gynecology of the British
Empire, Volume XI, Number III) devotes an extended study to the
bacteriology of peritonitis in relation to pelvic surgery. Peritonitis is
to be regarded as a secondary or terminal process in the course of other
diseases, many of which may, in themselves, be without dangerously
serious import. The avenues through which infection may enter are:
(i) Accidental or operation wounds; (2) Rupture or perforation of
a hollow viscus', a cyst, or an abscess; (3) Passage of germs from an
infected, but not perforated, hollow viscus, cyst or abscess ; (4) Indirect
infection of blood extravasated into the peritoneal cavity in such quan-
tities as to be not readily absorbed; (5) Infection by way of the blood-
stream.

The writer, after many observations in cases of peritonitis in gen-
eral, comes to the conclusion that certain types of the disease may be
recognized and differentiated according to the kind of infecting agent.
The organisms found were, in order of frequency, the staphylococcus
albus, the colon bacillus, the streptococcus, bacillus pyocyaneus, pneu-
mococcus, gonococcus, and staphylococcus aureus. Although the
staphylococcus albus was the organism most frequently found it is
thought to exercise a beneficial influence when associated with other
germs as it causes a marked phagocytosis. The colon bacillus is the
most important causative factor in peritonitis, the type of the inflamma-
tion varying with the virulence of the infection. The streptococcus
was rarely found, but when present gave rise to a rapidly fatal fonn of
the disease. Of rare occurrence as causes of peritonitis are the bacillus
pyocyaneug, the pneumococcus, and the gonococcus.

In considering peritonitis arising from diseases of the female pelvic
organs, the author states that the relative frequency is changed. The
less virulent infecting agents are more common in inflammation con-
fined to the pelvic peritoneum. Peritonitis of pelvic origin is consid-
ered under five divisions: (i) Extrauterine gestation; (2) Salpingitis:
(3) Inflamed ovarian cysts; (4) Infections connected with pregnancy;
(5) Accidental infections.

(i) Extrauterine Gestation, — In seventeen cases examined, a
staphylococcus albus of low virulence was isolated in each case. The

132 ORIGINAL ABSTRACTS.

infection starts in blood clots resulting from rupture of the sac. The
same organism was present in cases of intraabdominal hemorrhage
following rupture of the liver and spleen.

(2) Salpingitis, — Tubal inflammation is the most common cause of
peritonitis met with in gynecological surgery. The process is usually
of a comparatively mild type, occurring either by direct extension or
through rupture. The pus sac, in case of salpingitis, generally speak-
ing, contains the gonococcus or is sterile. Cultivation of the gonococcus
is so difficult that this fact may account for the repeated failure of
many observers to recognize the organism as a cause of peritonitis.
Since the inflammatory process in cases of gonorrheal peritonitis is of
such a mild character, it is rarely necessary to employ drainage.

(3) Inflamed Ovarian Cysts, — Only three cases were investigated
bacteriologically. Two of the cases showed a colon bacillus infection
of the cyst contents, and the third a streptococcus infection of the cyst
with staphylococcus albus present in the peritoneal exudate.

(4) 'Infections connected ivith Pregnancy,^— No examples of these
infections occurred. From a study of the literature, the peritonitis
following puerperal sepsis is often of streptococcus origin and is gen-
erally fatal.

(5) Accidental Infections. — Any of the organisms mentioned may
be the cause of postoperative peritonitis, the kind of infection depending
on the location of the field of operation. One case of fatal postoperative
peritonitis due to the bacillus pyocyaneus is mentioned. There was
also one instance of pneumococcus peritonitis.

From the bacteriological investigations, the author draws his con-
clusions, regarding treatment, under the following divisions:

( 1 ) Operative Treatment. — Since the recovery of a patient suffer-
ing from peritonitis depends largely on the leucoc3rtes of the exudate
acting as phagocytes, the surgeon should limit his operative inter-
vention to thorough drainage and local cleansing. No unwarranted
attempts should be made to remove diseased structures, and the
leucocyte barrier must not be washed away by copious irrigation. In
cases of intraabdominal or intrapelvic hemorrhage, the blood may be
removed by irrigations of salt solution as the infection at first is mild,
and there is always danger of after-infection of blood clots by virulent
organisms.

(2) Drug Treatment. — The writer merely considers the inadvis-
ability of using opium. This drug masks the symptoms, may be a
contributory agent in causing intestinal paralysis, and, according to
Dudgeon and Ross, inhibits leucocytosis.

(3) Specific Serum Treatment. — In all cases of peritonitis the
writer urges an attempt to early recognize the infecting agent and
then to employ a corresponding multivalent serum. Results, so far,
in Sargent's experience with serum therapy, have been "sufficiently
suggestive to w^arrant an extensive trial" of the method. c. G. p.

EXAMINATION OF RESPIRATORY PASSAGES. 133

PEDIATRICS.

Bv ARTHUR DAVID HOLMES. M. D..C. M.. Detroit, Michigan.

THE FREQUENCY, PROGNOSIS AND TREATMENT OF
LOBAR PNEUMONIA IN INFANTS AND CHILDREN.

KoPLiK (Boston Medical and Surgical Journal, Number I, 1905)
says double pneumonia in children is less frequent, but involement of
the upper lobes is more frequent as compared with adults. The prog-
nosis depends upon the age, severity, kind of infection and complica-
tions, but as a rule cases below the tenth year offer the best prognosis.
The author's greatest mortality occurred below the age of two and a
half years, and was greater in the winter months. A marked absence
of leucocytosis foreshadows an unfavorable termination. He says a
complicating otitis, pleurisy or empyema do not materially influence
the prognosis, if they are recognized early, and treated properly. Hy-
drotherapy is our sheet-anchor — sponging and cold compresses — in
controlling the temperature if it is doing harm. If the child does not
react well with cold, substitute tepid sponging. The author has not
seen much benefit from the use of oxygen, but advises thorough
ventilation, the room being kept at a temperature of 68° Fahrenheit.
Support the heart and administer strychnin. For the cough and pain
give codeia to the older, and paregoric to the younger children. For
collapse, place heat to the heart and extremities and administer camphor
and nitroglycerine.

LARYNGOLOGY.

By WILLIS SIDNEY ANDERSON. M. D.. Detroit, Michigan.

ASSISTANT TO THE CHAIR OF LARYNGOLOGY IN THE DETROIT COLLEGE OP MEDICINE.

THE CLINICAL VALUE OF THE DIRECT EXAMINATION

OF THE RESPIRATORY AND SUPERIOR

DIGESTIVE PASSAGES.

Carl von Eicken (Archiv, fUr Laryngology, XV, Number III)
gives a general resume of the value of autoscopic examinations as
developed by Kirstein. He speaks first of its value in the examination
of children, where it is so difficult to use a laryngoscope. It enables
the examiner to inspect the larynx by direct vision. Foreign bodies
in the larynx, or trachea, can be located and removed with great pre-
cision. In stenosis and displacements of the larynx, retropharyngeal
tumors, projections of the posterior wall of the pharynx, the direct
method offers many advantages. The author speaks of this method
in goitre, especially in diagnosing the endotracheal variety, or in malig-
nant disease of the gland where the trachea is involved. Certain
aneurysms of the ascending arch of the aorta, which are to be differ-
entiated from intrathoracic goitre, carcinoma of the esophagus and

134 ORIGINAL ABSTRACTS.

Other mediastinal affections can be accurately diagnosed by direct
tracheoscopic examinations. The bronchi and the esophagus, as well
as the trachea, can be examined by this method, and the surgery of
these passages can be made more exact.

GANGRENE OF THE TONSIL.
Charles W. Richardson {American Journal of the Medical
Sciences, October, 1905) reports two fatal cases in his own practice
and abstracts of three cases found reported in literature. The condition
is rare, the laboratory findings are of little help to diagnosis, and a fatal
termination seems to be the rule. One of the reported cases showed
upon examination a grayish, brownish, putty-like slough on the right
tonsil, anterior and posterior pillars and as far down the pharynx as
one could see. The odor of the breath is always offensive, the tempera-
ture is indicative of sepsis, and the prostration" is marked. The source
of infection in the cases reported could not be traced. One of the
author's cases was of the moist, the other of the dry, type of gangrene.

PROCTOLOGY.

Bv LOUIS JACOB HIRSCHMAN, M. D., Detroit, Michigan.

CUmCAL PR0FBS80R OF PROCTOLOGY IN THE DBTROIT COLLBCB OF MBDICINB.

THE TREATMENT OF HEMORRHOIDS.

Charles B. Kelsey, in The Therapeutic Gazette, Volume XXH,
Number HI, states that years ago he abandoned the use of the ligature
for the clamp and cautery. The clamp and cautery in his hands has
always been satisfactory, where the patients were willing to submit to
operation under general anesthesia. His reasons for preferring the
clamp to the ligature were at first that it caused less pain and gave
quicker convalescence; now he is convinced that the pain caused by
either operation depends far more upon the individual technique and
skill of the operator than upon the method of closing the operation.
He wishes to emphasize that the clamp and cautery is the last step of
the operation for piles and not the operation itself. The operation con-
sists of dissecting the pile from its attachments as far up toward its base
as is consistent with safety, and the dissected mass in the grasp of the
forceps is either cut off and tied, or clamped and cauterized. Kelsey
usually does the latter, but on some occasions still uses the ligature as
taught by Allingham.

Kelsey states that either operation may be done in suitable cases
under local anesthesia. Where the sphincters cannot be fully stretched,
general anesthesia is demanded. He absolutely opposes the White-
head and the "American" operation, on account of the many cases of
stricture and ulceration following them, and states that he abandoned
the injection treatment years ago, on account of its many septic
sequences, and inherent dangers. After a systematic search for some
method which would accomplish a cure without general anesthesia or

HEREDITARY SYPHILIS. 136

confinement to bed, Kelsey adopted the method of punctate cauteriza-
tion by means of the galvanocautery. His technique is, briefly: Ten
or fifteen minims of a weak eucain solution are injected into the most
prominent part of the tumor through the Kelsey speculum until disten-
sion is produced. After waiting for a few minutes to allow the anes-
thetic to take eflFect, a fine platinum cautery needle, heated to redness,
is plunged into the substance of the tumor. Not over two applications
are made at a sitting, and these not oftener than twice a week. If
much pain and soreness results it is well to wait a week for healing.
This treatment takes several wrecks to effect a cure, and the patient can
attend to his usual vocation. Kelsey reports cures of as long as ten
years standing in prolapsing and bleeding hemorrhoids, and has never
had an unpleasant complication or sequela.

DERMATOLOGY.

By WILLIAM FLEMING BREAKEY. M. D.. Ann Arbor, Michigan.

CUNICAL PROPBSaOlt OP DSKMATOLOGT AND STFHILOLOGT IN THE UNXVKMITT OV MICHIGAN.

AND

JAMES FLEMING BREAKEY, M. D., Ann Arbor, Michigan.

ASSISTANT IN DERMATOLOGY IN THE UNIVERSITY OP MICHIGAN.

INFLUENCE OF PATERNAL INHERITANCE ON HEREDI-
TARY SYPHILIS.

August Ravogli (American Journal of Dermatology, October,
1905) discusses inherent syphilis, paternal, maternal and both.

In many cases Colles' law is but a proof of latent infection, and a
woman married to a syphilitic man, may, during pregnancy, be infected
by her ow^n syphilitic child. This maternal infection may be severe,
scarcely perceptible or remain latent and after years appear as gum-
mous or ulcerative processes.

Syphilitic infection may be carried through the sperma as well as
through the placenta. In spermatic infections, the fetus, saturated
with lues, may infect the mother or the infection may remain latent in
the fetal system. In the latter case the mother remains healthy.

Hereditary syphilis must be divided into early hereditary and
retarded hereditary syphilis, dependent ijpon the amount of syphilitic
virus, the infection of both parents, the time elapsing from infection
and the morbid intensity of the virus.

In cases of paternal syphilis alone we more frequently find syphilis
hereditaria tarda manifesting itself even as late as the thirtieth year.
The symptoms are then of the tertiary type.

Manifestations of hereditary syphilis are more frequently found at
birth and during childhood.

Among the various evidences of hereditary syphilis are: peculiar
corneal inflammations often preceded by articular troubles ; Hutchinson
teeth; retinal and choroidal troubles; modifications in* the auditory

136 ORIGINAL ABSTRACTS.

apparatus ; various cerebral changes, as Jacksonian epilepsy or general
convulsions, softening from endoarteritis, infantile hemiplegia, hydro-
cephalus and idiocy; various pathological conditions of the skin,
mucous membranes, bones and other organs.

The prophylactic treatment should be directed through both parents
supplementary to treatment already taken. This consists of six months
of mercurial and iodic treatment before procreating and the same
treatment would better be continued to the mother through her ges-
tation. J. F. B.

NEUROLOGY.

By DAVID INGLIS, M. D., Detroit, Michigan.

PKOVBSSOR OP NBRYOUS AND MBNTAL OISBASKS IN THK DSTKOIT COLLBCB OP MBOICINB.

AND

IRWIN HOFFMAN NEFF, M. D.. Pontiac. Michigan.

ASSISTANT PHYSICIAN AT THB BASTBBN MICHIGAN ASYLUM.

THE EARLY OCULAR SIGNS OF DEMENTIA PARALYTICA.

HoLDEN {Journal of Nervous and Mental Disease, November,
1905, Volume XXXII, Number XI). The writer's conclusions are
bounded on seventy cases of paretic dementia which he believed to be
uncomplicated, that is, without cord involvement. The writer believes
that by selecting these early cases, unattended with tabes, he has more
nearly arrived at the condition of the pupillary reflex in paretic
dementia. It is interesting to note that optic nerve atrophy was not
found in one of the seventy cases reported, the author stating that he
has found pallor of the optic disc only when symptoms of tabes or of
nicotin poisoning complicate the cases of paretic dementia.

The writer's recapitulation is as follows: "As this table shows,
in true, uncomplicated paresis there is early in the disease almost
constant absence of the sensory reflex, in half the cases irregularity
of the pupils, in nearly half inequality of the pupils, in more than half
abnormally small pupils, in a fifth of the cases loss of light reaction,
in another fifth marked sluggishness of light reaction, and in a few
of those with diminished light reaction a diminution of convergence
reaction also." i. h. n.

PSYCHASTHENIA: ITS CLINICAL ENTITY
ILLUSTRATED BY A CASE.

Schwab (Journal of Nervous and Mental Disease^ November,
1905, Volume XXXII, Number XI). The writer quotes Janet, and
while corroborating his views, is inclined to think that Janet's ideas of
combining many symptoms and giving it one name is not to be at
present commended. He, however, believes that there is a disease
which can be distinguished from hysteria and neurasthenia, and as
illustrative of this publishes his case, with the detailed clinical history.

I. H. N.

i BALDNESS AND BREATHING. 137

EDITORIAL COMMENT.

BALDNESS ASCRIBED TO IMPROPER BREATHING.

Doctor Delos L. Parker, of Detroit, who has been experimenting
to determine, if possible, the factors leading to baldness, deduces some
very interesting conclusions. To summarize, the entire theory is based
on the contention that air, deposited in the alveoli of the lungs which
are not utilized in the process of respiration, develops, in the presence
of warmth and moisture, a poison which the investigator, in a series of
preliminary studies, designated trichotoxin. The substance gaining
entrance to the circulatory system, attacks the hair ( i ) by toxic effect,
and (2) by depositing a crust — dandruff — upon the cranial cutis. In
experimentation, Doctor Parker has been able to manufacture the
poison artificially by gathering exhaled air in bottles — partially filled
with water — and subjecting it to body temperature. By shaking the
flasks occasionally the proper degree of moisture is maintained. In the
course of four or five days the water is evaporated to dryness over a
water-bath, and a residual deposit, closely resembling frost on a window
pane, is observed. Microscopic examination discloses a crystalline
structure closely resembling uric acid, but tests demonstrate the absence
of this product. The deposit is composed of two substances, one of
which is readily soluble in absolute alcohol. By allowing the alcohol,
in which have been dissolved some of the crystals, to evaporate, the fact
was ascertained that the insoluble crystals are larger than the soluble.
Animal experimentation developed some interesting features. Injec-
tions of the insoluble crystals resulted in loss of hair, while the effect
of treatment, with the soluble crystals was merely a crust or scaly
deposit on the skin, with no destruction of hair. Doctor Parker con-
cludes that the insoluble product is the direct cause of baldness, while
the soluble product is the cause of dandruff. To the insoluble substance
the term trichotoxin — hair poison — still applies, but since the other
substance does not affect the hair, but does affect the secretion of the
sebaceous glands, the sebum, the term stearotoxin (meaning sebum
poison) has been originated to represent it.

In order to have the alveoli of all parts of the lungs utilized for
breathing purposes, and the conditions that permit the poison of bald-
ness to form prevented from being developed, the upper ribs must rise
and fall with each respiratory act. In persons not bald this always
occurs. In persons affected with baldness it does not occur. If this form
of breathing is practiced, baldness will not develop, and if it is re-estab-
lished and carried on continuously after being lost, baldness that may
have resulted from its absence will be repaired.

Doctor Parker intends to publish an extended account of his work
in the near future.

138 EDITORIAL COMMENT.

MEDICINE IX POPULAR MAGAZINES.

The importance of diffusing sound ideas of physiology and path-
ology among thinking people is generally accepted among those who
know. How difficult it is to secure reception for truth, and how easy
to spread error, are both only too well known.

A recent number of Current Literature illustrates these facts. It
contains two medical articles. One is on the subject of "Pneumonia,
Mice, and the Cold Cure," and will probably do no harm. The other
is entitled "Extraction of Gastric Juice from the Live Hog." This
opens with the somewhat illogical statement that "Natural gastric
juice is so essential to the development of therapeutic science that the
supply of the fluid threatens to be inadequate to meet the demand."
Just what this means the writer may know, but how well qualified he
is for taking up such a subject can be gathered from the next sen-
tence, about as absurd and groundless as can be imagined : "In pul-
monary tuberculosis the use of the natural gastric juice from an
extraneous source has been held a condition precedent to cure." Put
in simple language this can hardly mean anything else than that gastric
juice must be given to patients with pulmonary tuberculosis, if they
are to be healed. Perhaps some may have "held" this view, but how
remote it is from modern medicine needs no remark. The article then
quotes a newspaperese account of gastric fistula operations on pigs,
with side-tracking of the stomach, ending: "When gastric juice is to
be extracted, the hogs are raised into the air." If true, the animals
would be in the same element as the abstracter's ideas.

The question naturally arises. If the editorial omniscience is as
faulty in matters of literature, politics, and art, what sort of an authority
or guide is the periodical?

A RECORD OF THE HEAT INTENSITY OF RADIUM.

The investigations of the Swedish scientist. Angstrom, to deter-
mine the amount of heat evoluted by the product radium, are of suffi-
cient importance to arouse medical interest. The research of this
worker demonstrates that the heat evolutions remain practically con-
stant for a year, regardless of the nature of the surrounding medium,
and accordingly the conclusion is reached that the beta and gamma
rays form but an insignificant part of the total energy of the metal.
The apparatus and method of determining the amount of heat evoluted
were indeed simple. Radium bromid — 86.5 milligrams — was encased
in a small metal cylinder, in close proximity to a second cylinder of
similar construction, which contained a small manganine coil charged
with an electrical current. Accurate measurement of the heat evolu-
tions of the two cylinders was recorded by means of thermoelements.
The cylinder containing the coil was kept at a temperature identical
with that containing the radium, by varying the current traversing the

LIVE BABES FROM SUBJECTS OK LUES. 139

manganine coil, and in order to obviate error in measurement due to
a possible metallic difference in the cylinders alternation was resorted
to. The character of the metal employed in the cylinders apparently
exerted little influence in the result obtained since the amount of heat
was found to be 1.136 small calories per minute for each gram of the
metal employed, whether lead, copper, or aluminium cylinders were
utilized. The radium product investigated by Angstrom from Septem-
ber, 1903, to January, 1905, evidenced no apparent alteration in the
amount of heat evoluted. The heat effect of the metal would therefore
seem to be due to the internal activity of the alpha particles, or to some
agent which is decidedly different in character from the trio of rays
mentioned.

ANNOTATIONS,

OCCULT THERAPY IN THE OTTOMAN EMPIRE.

Even somnolent and superstitious Turkey is awakening to a reali-
zation of the fraud that is perpetrated by unscrupulous medical prac-
titioners, and a crusade against quackery of all kinds is now being
agitated. Although the people in general are vastly too ignorant to
appreciate skilled medical attendance, reputable practitioners are at last
aroused to action. As elsewhere, the quacks of the Empire flourish by
grossly deceiving the masses, most diseases being ascribed to the
malefactions of an evil eye, while occult therapy largely constitutes the
system of practice.

INSECTS AS SPREADERS OF INFECTION.

Meyer, a German physician, has conducted experiments with ants
to determine the alacrity with which the insects carry disease germs.
Some mice infected with typhoid were placed in a cage to which a
colony of ants had ready access. A second cage containing uninocu-
lated mice was placed so that the ants could gain entrance. Shortly
the uninfected mice were perceived to develop all the symptoms of the
disease. Plates of media over which the ants ran developed mouse
typhoid in pure culture, and the fact that the insects can carry infec-
tion effectively was evidenced when the investigator himself became
ill with the disease.

LIVE BABES FROM PREGNANT SUBJECTS OF LUES.

Gaucher announces a treatment for syphilitic pregnant women
which is calculated to insure a live, well-developed infant at full term.
Essentially, an important factor is the establishment of treatment
during the early stages of pregnancy. Mercury, the old specific sheet-
anchor, is the remedy, but especial stress is placed on the fact that a

140 MEDICAL NEWS.

readily absorbable preparation must be employed. Sublimate in pill
form for ingestion, and benzoate of mercury in alkaline solution for
subcutaneous injection, are prescribed. Of sublimate, a centigram is
administered, with a like amount of extract of thebane, twice daily.
The benzoate is employed in injections of two centigrams, once daily.
The ideal treatment contemplates alternation, giving the sublimate one
day and the benzoate the next, permitting frequent rests from treat-
ment during the pregnant state. In albuminuric conditions the dose by
injection should be decreased one-half, and when elimination is faulty
the tannate of mercury, two to ten centigrams, must succeed a period of
milk diet.

MEDICAL NEWS.

AMERICAN MEDICINE BECOMES A MONTHLY.

Doctor George M. Gould has announced the transformation of
American Medicine from a weekly into a monthly publication. At a
recent meeting of the stockholders there was an overwhelming senti-
ment in favor of certain changes of policy, and the directors of the cor-
poration were constituted a committee to inaugurate such changes as
might seem indics^ted after due deliberation. A new series monthly is
an innovation contemplated in the new policy. After giving assurance
that the present "scientific, professional, and literary standards" of the
weekly will be maintained in the monthly, the editor has this to say:

"The cause of independent medical journalism is growing more
important each year, and recognition of its value and necessity is becom-
ing more general in the profession. The professionally-owned journal
conducted in the interests of untrammeled opinion and speech, usually
the sole medium of expression for the minorities through whom progress
has always come, must necessarily encounter more difficulties than those
periodicals which represent interests solely commercial, or are the
mouthpieces of societies or other organizations, whether great or small.
It is a matter for congratulation that there is always an emergence from
such conditions into greater freedom and progress. Experience has
shown, moreover, that most of what is best worth while in the profes-
sion has been accomplished through the efforts of independent profes-
sional journals, though too frequently the final details of the measures
they have inspired or inaugurated must be left to the publications which,
representing large professional bodies and hence more powerful finan-
cially, deal naturally with measures which have become popularized and
thus represent "majority" views. The profession is vitally concerned
in the existence and power of its professionally-owned medical journals,
and a large part of this interest must be directed, if it is foresighted and
wise, to the cause of the independent medical journal. No efforts should
be spared to make recognition of these facts more general."

MINOR INTELLIGENCE. 141

MINOR INTELLIGENCE.

The Illinois Medical College is a beneficiary in the will of the late
Doctor Addison H. Foster, a prominent Chicago physician, who
bequeathed his valuable library to the institution.

Doctor Leonard Lawshe Skelton, professor of neurology and
psychiatry in the Illinois Medical College, died at his home in Chicago
on March 14, aged forty-three years. Doctor Skelton was graduated
from Northwestern University in 1885.

Ballard, Washington, is to have a new hospital for the treatment
of tuberculosis, smallpox and other contagious diseases. The projectors
have organized a company, the capital stock of which is $100,000, and
the plans contemplate a magnificent main building.

The path of mystic medicine does not seem to be strewn with roses
in any section of the country. A "mental healer" was recently con-
victed at Sea Breeze, Florida, after a trial lasting twelve days, and
sentenced to pay a fine of $500 and serve thirty days in jail.

Out of five hundred volunteers, one hundred physicians have been
chosen as subjects for experimentation by the Anti-Seasick League,
which meets in Lisbon during April. Various remedies for the affec-
tion will be tested, and a special steamer has been chartered that prac-
tical demonstration may be made.

Revocation of the charters of several of the transit companies oper-
ating in the Borough of Manhattan is threatened. The cars, besides
being of an antique design, are said to positively reek with filth. Since
they have not been painted in years, and are generally in a very dilapi-
dated condition, they are hygienically and otherwise a menace to health
and limb.

Carmen Sylva, in an article on "The Jews in Roumania," comes
to the defense of her countrymen in their treatment of the Jews, by
proclaiming that they are not inhospitable, but utterly poverty-stricken.
She argues that the country's wealth is not sufficient for the support of
foreigners and that her own people are barely able to obtain an
existence.

The suit instituted by a contagious-disease patient against the Pull-
man Car Company, to recover damages sustained by being refused
admittance to a passenger coach, has been won by the company, the
Supreme Court of Alabama contending that the operators of car sys-
tems have the right to exclude persons suffering from contagious and
infectious diseases.

A BILL has been introduced in the New York legislature which pro-
vides for the creation of a state commission to regulate the practice of
nursing. The measure provides for a commissioner and deputy, whose
salaries shall be $7,500 and $4,500 respectively; a secretary, whose
salary shall be $4,000 ; and a board of physicians. It is intended that
the fees of applicants shall cover the salary expenditure.

142 MEDICAl, NEWS.

Professor von Behring, whose startling declaration that he had
discovered a cure for tuberculosis was published some time ago,
recently stated, in an address at Berlin, that the milk of immunized
cows is a specific for the disease. Has the doctor unearthed two cures,
or has the therapy of his first alleged remedy inadvertently leaked out?

The Mississippi legislature recently defeated a bill to compel com-
pounders of proprietary and patent medicines to divulge their formulae.
Druggists of the state strongly denounced the measure as detrimental
to their interests, inasmuch as its passage would necessitate the publi-
cation of formulae which had taken years of experience to perfect.

Heidelberg is to have a new Cancer Institute, and in connection
with its opening next September, an International Congress of Cancrol-
ogy will be held. The local authorities are pledged to furnish funds for
the maintenance of the institution for fifty years. Nearly $200,000 has
already been subscribed. Czerny, chief of the surgical staff at Heidel-
berg, has resigned that post and will henceforth devote his energies to
cancer research.

Paul C. Freer, M. D., Pii. D., who until recently occupied the
chair of chemistry at the University of Michigan, is now editor-in-
chief of The Philippine Journal of Science, the first number of which
has made its appearance. The publication is issued by the Bureau of
Science and will chronicle the researches of the profession in the Philip-
pines, dealing especially with problems involving bacteriology, immunity
and tropical diseases.

Twenty-five thousand dollars has been set aside by the trustees of
Montefoire Hospital and Home for Chronic Invalids, in New York
City, for the assistance of former patients of the institution who have
either been cured or permanently relieved, the interest accruing from
the amount being utilized for the purpose. Patients at the county
branch of the institution — the Bedford Sanitarium for Consumptives —
are included among the beneficiaries of the fund.

The equipment of the Craig Colony for Epileptics is to be aug-
mented by the construction of five additional cottages, contracts for
which have recently been signed. When the structures are completed
and occupied the colony will comprise about one thousand two hundred
fifty patients. A bill is pending in the legislature for the appropriation
of $300,000, for the construction of new buildings, and in the event of
its passage the colony will be increased to eighteen hundred persons.

**The name Carnrick has for nearly half a century been a sufficient
guarantee to medical men of the ethical status of their preparations/*
The foregoing announcement has been circulated by an Eastern con-
cern presumably with the idea of gaining prestige, but an advertise-
ment in the last number of this journal advises the profession that the
instigator of the above quotation is not identified with the pioneer pharm-
aceutic firm of Reed & Carnrick, who assume responsibility for their
own products solely.

ACUTE CONTAGIOUS DISKASES. 143

RECENT LITERATURE.

REVIEWS.

OPERATIVE SURGERY.*

The fourth revised edition of this valuable work is now on sale.
Many improvements are noticeable in the illustrations. A number of
new ones are introduced, and many of the old ones have been changed
to conform to modern conceptions. The greatest changes are found in
the second volume. One finds described here by text and illustration
the latest methods of performing intestinal anastomosis, gastroenter-
ostomy, pylorectomy, and many other new and important operations
in the upper abdomen. One has only to read a chapter here and there
to be convinced that the book is modernized.

We take pleasure in introducing it to our friends who do surgery
because they can secure accurate knowledge frorn it, and to those who
read surgery because of its charming Myle. c. c. d.

*By Joseph D. Bryant, M. D., Professor of the Principles and
Practice of Surgery, Operative and Clinical Surgery, in the University
and Bellevue Hospital Medical College; Visiting Surgeon to Bellevue
and Saint Vincent's Hospitals ; Consulting Surgeon to the Hospital for
Ruptured and Crippled, Woman's Hospital, and Manhattan State
Hospital for the Insane, et cetera.

ACUTE CONTAGIOUS DISEASES.*

The authors have given to the profession a work that has long
been needed. We feel that in recommending it to our readers we
are only doing our duty. It should be in the hands of every health
officer and of those who have much to do with the acute contagious
disease*. Every important phase of the subject is fully considered by
men whose years of experience with these diseases cannot help but
enable them to speak with authority. It is a book that should be read
and reread. The illustrations are the best that have been produced.
Those who have had experience witjti the acute contagious diseases
will appreciate them, and those who are doubtful of the characters of
the closely allied eruptions will receive much help from a critical
differential study of them.

*A Treatise on Acute Contagious Diseases. By William M. Welch,
M. D., Consulting Physician to the Municipal Hospital for Contagious
and Infectious Diseases; Diagnostician to the Bureau of Health, et
cetera, Philadelphia, and Jay F. Schamberg, A. B., M. D., Professor of
Dermatology and of Infectious Eruptive Diseases, Philadelphia Poly-
clinic ; Consulting Physician to the Municipal Hospital for Contagious
and Infectious Diseases, and Assistant Diagnostician to the Philadelphia

144 RECENT LITERATURE.

Bureau of Health, et cetera. In one very handsome octavo volume of
781 pages, illustrated with 109 engravings and 61 full-page plates.
Cloth, $5.00, net; leather, $6.00, net; half morocco, $6.50, net. Lea
Brothers & Company, Publishers, Philadelphia and New York, 1905.

INTERNATIONAL CLINICS.*

This volume keeps up the excellent record made by Doctor Kelly
in the practical series it represents. Treatment, Medicine, Surgery,
Obstetrics and Gynecology, Ophthalmology and Pathology are the
topics for this number. It is difficult to select a few from so many
articles — twenty-five in all — ^but among the most useful for the general
practitioner may be named : "The Treatment of Some Common Gastric
Disorders," by Norman B. Gwyn ; "Empyema, with a Report of Thirty
Cases," by J. N. Hall ; "The Later Stages of Cirrhosis of the Liver," by
Sir Dyce Dickworth; "The Thyroid Gland — Its Anomalies of Secretion
and their Manifestations and Treatment," by Thomas R. Brown ; "The
Results of Operations in the Treatment of Diseases of the Stomach,"
by John B. Deaver; "Phlebitis, Thrombosis and Embolism Following
Abdominal and Pelvic Operations," by William A. Edwards; "The
Etiology and Early Diagnosis of Acute Peritonitis," by Benjamin T.
Tilton. Charles F. Craig has a very thorough paper on the "Symptom-
atology and Diagnosis of Malta Fever," and Aldred S. Warthin one on
"An Experimental Study of the Effects of Rontgen Rays upon the
Blood-Forming Organs, with Special Reference to the Treatment of
Leukemia." As before, the series warmly deserves the study and
support of the profession.

*A Quarterly of Illustrated Clinical Lectures and Especially Pre-
pared Articles, et cetera, et cetera. Edited by A. O. J. Kelly, A. M.,
M. D. Volume IV. Fifteenth Series. 1906. Philadelphia and London :
J. B. Lippincott Company, 1906.

THE PRACTITIONER'S VISITING LIST.*

This book is well adapted to make a physician's book-keeping
reliable and accurate. It is complete in every respect.
*Lea Brothers & Company, 1906.

PROGRESSIVE MEDICINE.*

Progressive Medicine for June, 1905, contains the following
subjects: Hernia; Surgery of the Abdomen Exclusive of Hernia;
Gynaecology ; Diseases of the Blood ; Diathetic and Metabolic Diseases ;
EHseases of the Spleen, Thyroid Gland, and Lymphatic System; and
Ophthalmolog}'. Each section brings into convenient form the year's
work on the lines indicated. A comprehensive index makes the book
valuable for rapid reference.

*Lea Brothers & Company, Philadelphia and New York.

% ite^ian anlr Surgeon

A PROFESSIONAL MEDICAL JOURNAL.

VOLUME XXVIII. APRIL, 1906. NUMBER IV.

ORIGINAL ARTICLES-

MEMOIRS.

PATHOLOGIC PHYSIOLOGY OF THE TRACTUS

GENITALIS.

By BYRON ROBINSON, B. S., M. D., Chicago, Illinois.

PROPBSSOR OF CYNKCOLOGV AND ABDOMINAL SURGBKY OF WOMBN IN THB ILLINOIS MEDICAL COLLBGB.

For over a decade I have been attempting to make prominent in
gynecologic teaching, pathologic physiology, disordered function,
rather than pathologic anatomy, changed structure. It seems to me
that disorder-functions or pathologic physiology of the tractus geni-
talis impresses itself more indelibly on the student's and practitioner's
mind than pathologic anatomy. Besides, in gynecologic practice patho-
logic physiology occurs tenfold more frequently in the genital tract than
pathologic anatomy. For the gynecologist pathologic physiology pre-
sents innumerable views of practical interest. Pathologic physiology
teaches that the circulation of an organ is a fundamental factor in com-
prehending its disease and administering rational treatment. It takes an
inventory of the volume of blood which streams through the organ as a
fundamental factor in comprehending its diseases and administering
rational treatment. It takes an inventory of the volume of the blood
which streams through the organs at different stages and conditions.
We wrote years ago that the arteries of different viscera were supplied
with automatic visceral ganglia, and we christened the peculiar nerve
nodes found in the walls and adjacent to the uterus, oviducts and
ovaries, as "Automatic Menstrual Ganglia." The automatic menstrual
ganglia complicates the blood supply oi the tractus genitalis by chang-
ing its volume during the different sexual phases. In pueritas the
blood stream of the tractus genitalis is quiescent as well as its paren-
ch>Tnatous cells; in pubertas it is developing as well as proliferating
parenchymatous cells. In menstruation the blood stream is active with
active parenchymatous cells. In the puerperium there is retrogression

146 ORIGINAL ARTICLES.

of blood stream and an involution of parenchymatous cells. The
climacterium is the opposite of pubertas — subsidence, the decrease
of blood volume and parenchymatous cells. Senescence is a repetition
of pueritas — the quiescence of the genitals, their long night of rest.
The circulation of an organ quotes its value in the animal economy.
It rates its function. Observe the enormous volume of blood passing
through the kidney or pregnant uterus in a minute.

To study pathologic physiology of any visceral tract we iViust
possess clear views as to its physiology. The physiology of the tractus
genitalis is: (i) Ovulation; (2) peristalsis; (3) secretion; (4)
absorption; (5) menstruation; (6) gestation; (7) sensation.

(i) On account of the numerous theoretic views connected with
Ovulation and lack of space we will omit the general discussion on
the pathologic physiology of ovulation. It is well known that ovulation
has a wide physiologic range. We do not know the life of an ovum
or corpus luteum. It was once supposed that a corpus luteum was a
sign of pregnancy and the supposition gained legal or judicial position.
We know that this is an error. I have found two corpora lutea on one
ovary of a lamb which had not been pregnant. The internal secretion
of the ovary is important and chiefly manifest by marked symptoms
on removal of both ovaries — neurosis, accumulation of panniculus
adiposus, extra growth of hair, diminished energy and ambition. These
symptoms may occur in women possessing both ovaries, hence, we
would conclude that pathologic physiology of ovarian secretion existed.
The sensation of the ovary occupies a wide zone of pathologic physi-
ology in the mental and physical being. Forty per cent of women
visiting my office remark, "I have pain in my ovaries." On physical
examination we find the following conditions: First and fore-
most in the vast majority of women who complain of pain in the
ovaries palpation of the ovaries elicits no tenderness on pressure.
However, the pain of such women is located bilaterally in the area
of the cutaneous distribution of the ileohypogastric and ileoin-
guinal nerves. It is a skin hyperesthesia — a cutaneous neurosis.
The bilateral iliac region of cutaneous hyperesthesia corresponds to the
segmentation or somatic visceral (ovarian) area, and presents a fre-
quent varying zone of sensory pathologic physiology. In the vast
majority of women complaining of ovarian pain no disease of the ovary
can be detected — it is cutaneous hyperesthesia of the ileoinguinal and
ileohypogastric nerves.

(2) Peristalsis (excessive, deficient, disproportionate).

(a) Excessive peristalsis of the tractus gentalis (uterus and
oviducts) may occur at menstruation, during gestation, parturition by
the presence of myomata, during the expulsion of blood coagula,
placenta during congestion. The phenomena of peristalsis in the
uterus and oviduct differs from the form and distribution of the mus-
cularis. The myometrium during gestation is in continual peristalsis —
uterine unrest. By placing the hand on the abdomen of a four-month

TRACTUS GENITALIS.

147

FIGURE I.— SYMPATHETIC NERVES SHOWING THE ORIGIN OF^iTHE

GENITAL NERVES.

S, abdominal brain : B, showing oriirin of Hpermatic (ovarian) ; F, shows origin of right genital
nerve on the spermatic (ovarian artery) ; J, presents the plexus intenliacus which orig-
inates in the plexus aorticus. This illustration was drawn with extreme care from a
sperimf^n which I dissect^Mi under alcohol. It presents what I call the swan-shaped
ureters which are diluted and prevents ureteral valves (V). IV, presents the anastomosis
of the plexus ureteritis with the plexus spermaticus (ovaricus).

148 ORIGINAL ARTICLES.

gestating woman one can feel the uterine muscular waves. The ges-
tating uterus is always prepared for an abortion but the cervix, the sen-
tinel on guard, checks the proceeding. Fright will produce such violent,
disordered myometrial peristalsis as to break through the guarding
cervix. Many women during gestation experience considerable pain
(supersensitive uterus) from excessive uterine peristalsis — it is patho-
logic physiology. Uterine peristalsis may be sufficiently excessive to
rupture the myometrial wall. The "after-pains," puerperal pains, is
excessive peristalsis in an infected myometrium. Frequently the severe
pelvic pain during menstruation is excessive uterine and oviductal peris-
talsis due to its extramenstrual blood supply. It is chiefly the exces-
sive peristalsis at menstruation that forces many women to assume rest
in bed, for, with anatomic rest (maximum quietude of bones and volun-
tary muscles) and physiologic rest (maximum quietude of visceral
muscles) the uterine peristalsis will exist at a minimum. Excessive
oviductal peristalsis may produce pain of varying degrees. In exces-
sive peristalsis the automatic menstrual ganglia are stimulated by extra
quantities of blood or by other irritation.

(b) Deficient peristalsis of the tractus genitalis (uterus and ovi-
ducts) is not uncommon. Uterine inertia is an example known to
every obstetrician. Deficient uterine peristalsis allows hemorrhage in
the fourth and fifth decades of woman's life. Deficient peristalsis
allows extraglandular secretion (leucorrhea).

(c) Disproportionate peristalsis is disordered, wild muscular move-
ments in different segments of the uterus or oviduct.

(3) Secretion (excessive, deficient, disproportionate).

(d) Excessive secretion from the genital tract, pregnant or non-
pregnant, has an extensive range and varying quantity. The excessive
secretion zone in the tractus genitalis has an important bearing in prac-
tice. Typical pathologic physiology may be observed in the pregnant
woman from whose uterus may flow several ounces of white mucus
daily — no pathologic anatomy is detectable. Excessive uterine secretion is
a common gynecologic matter. The glands may not be embraced suffi-
ciently firm by the myometrium. The automatic menstrual ganglia are
diseased, insufficiently supplied by blood or the myometrium is degen-
erated. Flaccid uteri secrete excessively. Excessive secretion and its
Muid currents allows insufficient time for localization of the ovum.
Excessive uterine secretion is, from apt bacterial media, liable to become
infected. During excessive secretion physical examination frequently
detects no palpable pathologic anatomy — merely physiology has
exceeded its usual bounds.

(e) Deficient secretion of the tractus genitalis is not so manifest as
its opposite. The mucosa of vagina and uterus present excessive dry-
ness, dessication, practically as visceral functions are executed by means
of fluids, pathologic physiology is in evidence ; dryness and abrasion of
the mucosa, local irritation, chafing, local bacterial development, dys-
parunia, dysuria, defective import of spermatozoa and export of ova

TRACTUS GENITALIS.

149

FIGURE IT.--PP:LVIC BRAIN (Adult).

Drawn from my o-wn disnection. A, pelvic brain. In this cane it is a ganRlionat^'d plexus pos-
sessing a wide meshwork. Also the pelvic brain is located well on the vagina, and the
visceral sacral nerves (pelvic splanchnics) are markedly elongated; V, vagina; B, blad-
der; O, oviduct; Ut, uterus; Ur, uret^-r ; R, rectum ; P L, plexus interiliacus (left) ; P R,
plexu.sint«riliacus (right); N, sacral ganglia; Ur, uret^^r: 5 L, last lumbar nerve; i, ii,
ili, iv, sacral nerves; 5, coccygeal nerve. Observe that the great vesical nerve (P) arises
from a loop l)etween the ii and iii satjral nerves. G S, great sciatic nerve.

150 ORIGINAL ARTICLES

ending in sterility. Deficient secretion means that waste-laden fluids
are bathing and irritating the thousands of lymph channels in the body.
Deficient secretion or excessive dryness of the genital mucosa — ^patho-
logic physiology with no perceptible pathologic anatomy — is not uncom-
mon iq gynecologic practice. Oily applications to subjects with deficient
genital secretion may be required for protection of exposed nerve per-
iphery as abrasion, fissure, ulcers and also for relief.

(f) Disproportionate secretion may occur in the different segments
of the genital tract, unequal, excessive, deficient, irregular.

(4) Absorption (excessive, deficient, disproportionate).

(g) Excessive absorption presents two views, namely, a dryness of
the genital mucosa from excessive absorption of the mucal fluids. This
resembles the conditions arising in deficient secretion of the genital tract
(see e). Again the mucosa of the genital tract excessively absorbs.
Deleterious substances lying on its mucosa — septic or toxic. Excessive
absorption in the genital tract pathologic physiology, resembles excess-
ive absorption and conditions in other localities as the absorption of
poison ivy, lead, arsenic among art workers. The pathologic physi-
ology possesses a wide range for some experience no ill-effects while
others are severely or even fatally ill from absorption of same substance
under similar conditions.

(h) DeHcient absorption in the tractus genitalis produces an exces-
sive discharge, the decomposition of which lays the foundation of bac-
terial multiplication and excoriation of mucosa and skin.

(i) Disproportionate absorption occurs in the different segment of
the tractus genitalis and presents pathologic physiology. However,
lack of space makes it impractical to discuss it.

(5) Sensation (excessive, deficient, disproportionate).

(j) Excessive sensation in the tractus genitalis presents a wide
zone of pathologic physiology. Vaginismus is the extreme type of
genital hyperesthesia. The introitus vaginae of perhaps fifty per cent
of women is supersensitive. When I was a pupil of Mr. Lawson Tait
he had a patient, a recently married woman, from whom- the husband
was sueing for divorce as her genital hyperesthesia was so excessive that
coition or examination was intolerable. She had to be anesthetized to
be examined, which was also suggested for impregnation with the hope
that gestation would relieve the condition. Supersensitiveness of the
pudendum is not an uncommon matter in gjnecologic practice and with-
out demonstrative pathologic anatomy. The pathologic physiology of
excessive sensation in the tractus genitalis has a wide range of variation
and degree of intensity, goirie subjects may be afflicted with excessive
sensation in the pudendum for many years. The excessive sensitive
genitals may be manifest in the uterus or ovaries. A small number
complain of tenderness and soreness in the internal genitals which can-
not be detected as pathologic anatomy — simply excessive sensation.
The gestating uterus may be so sensitive that it disorders adjacent vis-

TRACTUS GENITALIS.

151

cera by reflexes. The treatment of subjects with excessive genital
sensation requires unlimited time with continuous patience.

(k) Deficieftt sensation of the tractus genitalis is encountered.
With such subjects practically no orgasm occurs during coition to
which they are indifferent. Practically little or no treatment is required.

FIGURE III.— HISTOLOGY OF PELVIC BRAIN.

A, drawn from the pelvic brain of a ^irl Heventeen years of age. The ganglion cells are com-
pletely develoi>ed. B, drawn from the pelvic brtdn of a three months' normal gestation.
The ganglion cells are complet<»ly developed. Observe the enormous mass of connective
tissue present. C, child l}4 years old. A nerve process courses within the ganglion.
Few and small ganglion cells incompletely developed. D, girl 1^ years old. A nerve
process branches and reunites it«elf with the intercellular substance. B, girl 0 years
old. The ganglion cells are presenting development. (Redrawn after Doctor Babura
Haahmoto).

(1) Disproportionate sensation in the genital tract is irregular,
indefinite, disordered, sensation arising and disappearing in its different
segments practically without reason or rhyme.

{6) Menstruation (excessive, deficient, disproportionate).

I will present this subject through a clinical patient. Brief remarks
on common examples of pathologic physiology in the tractus genitalis

162 ORIGINAL ARTICLES. •

will suffice to illustrate and suggest. As the most apt subject to illus-
trate pathologic physiology in the tractus genitalis I will choose that of
menstruation.

To illustrate the value of pathologic physiology and the methods of
teaching it we will place a gynecologic patient before a student to elicit
clinical data in reference to menstruation as landmarks for diagnosis.
A landmark is a point for consideration physiologic, anatomic, patho-
logic. To teach gynecology- we should instruct by means of disordered
function as a base. Menstruation is the first practical function of the
genital tract. Hence the student asks in menstruation four questions,
namely: (a) How old were you when the monthly flow began? The
patient may answer: eleven (premature), fifteen (normal), or nine-
teen (delayed) years of age. This answer presents a wide range of
beginning of the menstrual function. Now, the girl who begins to
menstruate at eleven generally represents pathologic physiology, but
not pathologic anatomy. For example, the girl who begins at eleven
(menstratio precox) will in the majority of cases menstruate profusely
and prolonged. She will experience a late climacterium. An early
menstruation indicates a late climacterium. Though one can palpate
practically no pathologic anatomy, the tractus genitalis is prematurely
developed at eleven years of age, premature in dimension (nerves,
blood, lymph, parenchyma) and function (menstruation, gestation).
The blood stream to the genitals is prematurely excessive, the auto-
matic menstrual ganglia are large and prematurely active. Her men-
strual life is accompanied by excessive blood supply and hemorrhage,
disordered function, active parenchymatous cells, prolonged reproduc-
tiveness. It is pathologic physiology, exaggerated function but practi-
cally not pathologic anatomy. The girl who begins at fifteen is prac-
tically normal during her menstrual life. No pathologic anatomy nor
pathologic physiology is manifest. The girl who begins to menstruate
at nineteen (menstratio retarda) is delayed with her menstrual func-
tion ; late menstrual appearance means early climacterium ; it frequently
indicates amenorrhea and dysmenorrhea. It generally means defect-
ive genital blood supply and limited parenchymatous cellular activity.
It is pathologic physiology, disordered function, limited productiveness,
but frequently no palpable pathologic anatomy presents. .It is a fact,
however, that in some cases atrophy or myometritis is palpable patho-
logic anatomy and should not be confused with subjects possessing
pathologic physiology.

(b) The student asks the patient: Is the monthly flow regular?
The answer may be, regular or irregular. The patient with irregular
menstruation is afflicted with pathologic physiology but no pathologic
anatomy may be detected. It may be stated, however, that the auto-
matic menstrual ganglia require about eighteen months of vigorous
blood supply to become sufiiciently strong and established to act regu-
larly monthly. The same condition exists in the automatic vi-^ceral

TRAC rUS GENITALIS.

15S

ganglia ( Auerbach's and Billroth-Meissner's) of the tractus intestinalis
of a child.

(c) The student, thirdly, asks the patient: Is the monthly flow
painful? The answer may be, yes or no. A normal menstruation
should be painless. Dysmenorrhea or painful menstruation is patho-

KIGURE IV.— SYMPATHETIC NERVES.

Dii«t*ctt^d with extrt^me care under al(!ohol, showinjc origin of the genital nerves flroni the
abdominal brain, from the plexu-s ovaricus O on the right, and from the plexu.s ovaricua P
on the left. On the right, M pre.sents the anastomosis of the plexus uret^'ris with the
plexus ovaricus. Ph is the plexus interiliacus ari.sing proxlmally from the plexus aorti-
eus, and ending distally in the bilateral pelvie brain.

logic physiology, disordered function, but frequently no pathologic
anatomy can be detected. At menstruation the blood volume in the
tractus intestinalis rapidly increases, blood pressure is raised, compress-
ing or traumatizing the nerves to a degree. Limited hematoma may
occur in the endometrium, congestion is intense, inciting vigorous and

154 ORIGINAL AKTlCLtS.

disordered peristalisis of the uterus and oviducts. In short the trauma
oi" shock of menstruation of the genital tract irritates it into a state of
pain. It is a state of pathologic physiology, disordered function, but
no pathologic anatomy may be palpable. The affliction is functional.

(d) The student finally asks the patient: How many days does
the monthly flow continue? The answer may be, two to eight days.
Two days is deficient (amenorrhea or oligemia) ; four days is normal,
eight days is excessive (menorrhagia). I have examined scores of
gynecologic patients with over a week's flow, menorrhagia, but in many
of them no pathologic anatomy or change of structure could be detected.
It is typical pathologic physiology, disordered unusual function. The
subject is like a watch with an excessively powerful mainspring. The
watch has no detectable pathologic anatomy, no change of structure.
The mainspring, the automatic ganglia, is excessively active. The
organ is working excessively, the watch is gaining time. The auto-
matic ganglia are prematurely powerful, the watch spring is too strong.
Menorrhagia in many subjects is typical pathologicl physiology. The
pathologic anatomy, if it exists, is too subtle for us to detect. The
adult life of the tractus genitalis presents an excellent field for study
and teaching in pathologic physiology. Its several periodic functions,
its changing volume of circulation, the limited life of its parenchyma-
tous cells and its automatic menstrual ganglia afford a useful field for
study and development of pathologic physiology.

(7) Gestation presents many phases of pathologic physiology.
There is the typical pathologic physiology, namely, emesis, albuminuria,
hypertrophy of left ventricle, pigmentation, capricious appetite, consti-
pation, increase of panicular adiposus, the peculiar gait, venous engorge-
ment (edema), excessive glandular secretion, osteomalacia. The vom-
iting of pregnancy may present a vast zone from slight regurgitation
of food to profound anemia due to limited nourishment — where path-
ologic physiology alone tells the tale. The normal physiologic nerve
relations between the tractus genitalis (uterus) and tractus intestinalis
(stomach) have become disordered. No pathologic anatomy is demon-
strable. Constipation (pathologic physiology) is liable to arise during
gestation because the normal physiologic blood supply of the tractus
intestinalis is robbed to supply the increasing demand of the gestating
genital tract. The albuminuria of pregnancy is doubtless partially due
to pressure of the expanding uterus on the ureters and veins obstruct-
ing venous and urinal flow. The normal physiologic relations between
the tractus urinaria and the gestating tractus genitalis has become pro-
jected into the field of pathologic physiology. Pathologic anatomy is
not in evidence except as ureteral dilatation — a secondary matter. A
comprehensive view of pathologic physiology aids in diagnosis and
treatment. It will impress the practitioners with the utility of visceral
drainage, the administration of ample fluids at regular intervals to
relieve the system of waste-laden blood — irritating substances. Path-
ologic physiology teaches us to restore function and frequently patho-
logic anatomy will take care of itself.

TRACTUS GENITALIS. 166

TREATMENT OF PATHOLOGIC PHYSIOLOGY OF THE TRACTUS

GENITALIS.

Since pathologic physiology is the zone between physiology and
pathologic anatomy, it should be amenable to treatment. A diagnosis
by exclusion should be made. It must be remembered that in the
physiology the entire six abdominal visceral tracts are balanced har-
monious, functionating without friction — no reflexes dashing hither and
yon disturbing the exquisitively poised visceral physiology. In the
treatment of pathologic physiology of the tractus genitalis it should be
remembered that the genitals are not vital for life, but that the richly
nerve-supplied genitals dominate the mental and physical existence of
woman. In the treatment of pathologic physiology there are the sub-
jects of periodic hyperemia, congestion, hemorrhages, excessive glan-
dular secretions, disturbed sensation (hyperesthesia). First and fore-
most in the treatment of pathologic physiology of the tractus genitalis,
the adjacent visceral tracts must be regulated to normal states as to
drainage but especially as to the physiologic condition of blood. Fre-
quently by producing daily evacuation of the digestive tract and
increasing the renal secretion by ample fluids the pathologic physiology
of the genital tract improves. The genitals should be examined for
adherent prepuce, pudendal fissure, pruritus pudendae, or other point of
irritation. The other five abdominal visceral tracts (urinarius, intesti-
nalis, vascularis, lymphaticus, nervosus) should be examined for
points of visceral irritation. The frequent splanchnoptotic condition
must be studied and remedied.

/. VISCERAL DRAINAGE.

For many years I have applied a treatment to such subjects which
I term visceral drainage. Visceral drainage signifies that visceral tracts
are placed at maximum elimination. The waste product of food and
tissue are vigorously sewered before new ones are imposed. The most
important principle in internal medication is ample drainage for every
visceral tract. The residual products of food and tissue should have a
maximum drainage in health. I suggest that ample visceral drainage
may be executed by means of: (A) Fluids; (B) Food.

(A) Visceral Drainage by Fluids.

The most effective diuretic is water. One of the best laxatives is
H2O. One of the best stimulants of renal epithelium is sodium
chloride (one-half to one-quarter physiologic salt solution). Hence I
administer eight ounces of half normal salt solution to a patient six times
a day, two hours apart. (Note. — Sodium chloride is contraindicated in
parenchymatous nephritis). Forty-eight ounces of half normal salt
solution daily efficiently increases the drain of the kidney. It main-
tains in mechanical suspension the insoluble uric acid; it stimulates
other matters; it aids the sodium, potassium, or ammonium salts to
form combination with the uric acid, producing soluble urates. The

156 ORIGINAL ARTICLES.

half normal salt solution effectively stimulates the peristalsis and
epithelium of the tractus intestinalis inducing secretions which liquify
feces, preventing constipation.

(B) Visceral Drainage by Foods.

The great functions of the visceral tract — peristalsis, absorption,
secretion, sensation — are produced and maintained by fluids and foods.
To drain the tractus genitalis and adjacent visceral tracts which should
be excited to peristalsis, foods which leave an indigestible residue
only are appropriate. All visceral tracts must be stimulated to maxi-
mum peristalsis, secretion, and absorption in order to aid that of the
tractus genitalis. Rational foods must contain appropriate salts whose
bases may form combinations which are soluble, as sodium, potassium,
and ammonium combined with uric acid and urates to form soluble
urates. The proper foods are cereals, vegetables, albuminates (milk,
eggs), mixed f(X)ds. Meats should be limited as they enhance excessive
uric acid formation. In order to stimulate the epithelium (sensation)
of the digestive and urinary tract with consequent increase of peris-
talsis, absorption and secretion in both I used S part or multiple of an
alkaline tablet of the following composition: Cascara sagrada (1-40
grain), aloes ( 1-3 grain), sodium carbonate ( i grain), potassium car-
bonate ( 1-3 grain), magnesium sulphate (2 grains). The tablet is used
as follows: One-sixth to one tablet (or more as required to move the
bowels freely, once daily) is placed on the tongue before meals and fol-
lowed by eight ounces of water (better hot). Also 10 a. m to 3 p. m.,
and at bedtime one-sixth to one tablet is placed on the tongue and fol-
lowed by a glassful of any fluid. In the combined treatment one-third
of the scxlium chloride tablet (containing eleven grains) and one-sixth
to three alkaline tablets are placed on the tongue together every two
hours, followed by a glass of fluid. The eight ounces of fluid may be
milk, buttermilk, eggnog — nourishing fluid. This method of treatment
furnishes alkaline bases (sodium, potassium and ammonium) to com-
bine with the free uric acid in the urine, producing perfectly soluble
alkaline urates and materially diminishing the insoluble free uric acid in
the urine. Besides the alkaline laxative tablet increases the peristalsis,
absorption and secretion of the intestinal tract, stimulating the sensation
of the mucosa — aiding evacuation. I have termed the sodium chloride
and alkaline laxative method the visceral drainage treatment. The
alkaline and sodium chloride tablets take place of the so-called mineral
waters. I continue this dietetic treatment for weeks, months, and the
results are remarkably successful, especially in the pathologic physi-
ology of the visceral tracts. The urine becomes clarified like spring
water and increases in quantity. The tractus intestinalis becomes freely
evacuated, regularly, daily. The caliber of the tractus vascularis
becomes a powerful fluid volume to carry oxygen and food to tissue,
while the effete matter and waste products are rapidly swept into the
.sewer channels. The blood is relieved of waste-laden and irritating

TRACTUS GENITALIS. 167

material. The tractus cutis eliminates freely and the skin becomes
normal. The appetite increases. The sleep improves. The patient
becomes hopeful, natural energy returns. The sewers of the body are
drained and flushed to a maximum.

IL— VAGINA!. DOUCHE.

(i) The kind of instrument to employ is a fountain syringe of
fourteen-quart capacity. The simplest and most economic vaginal
syringe is a fourteen-quart wooden pail, the kind generally used in
transporting candy or tobacco.

(2) The location of the syringe should be four feet above the
patient.

(3) The quantity of fluid administered in the beginning should be
two quarts for patients unaccustomed to its use and four quarts to those
accustomed to its use. The quantity should be increased a pint at each
administration to fourteen quarts.

(4) The temperature of the douche should be 105° in the beginning
and increased one degree at each administration until it is as hot as it
can be borne (115° to 120*").

(5) The duration of the douche should be ten minutes for each
gallon.

(6) The time to administer the douche is in the evening immedi-
ately before retiring and in the morning (after which the patient should
lie horizontally for forty-five minutes).

(7) The position of the patient should be lying on the back.

(8) As to method of administering the douche the patient should lie
on a sufiiciently inclined plane to allow the returning fluid to drain into
a vessel (pail, pan). The ironing board, wash-tub or board resting on
the bath-tub serves convenient purposes. The douche should not be
administered in the bed (unless ordered), standing or sitting postures
or on the water-closet.

(9) As to ingredients a handful of sodium chloride and a teaspoon-
ful of alum should be added to each gallon, the sodium chloride to
dissolve the mucus and pus, to act as an antiseptic and to prevent
reaction, while the alum is to astringe, check waste secretions and
harden tissue.

( 10) The vaginal tube employed in administering the douche should
be sterilized, boiled, and every patient should possess her own vaginal
tube. The most useful vaginal tube is the largest that can be con-
veniently introduced or the one that distends the vaginal forces so that
the hot fluids will bathe the greatest surface area of the proximal or
upper end of the vagina.

(11) The utility of a vaginal douche is: (a) It contracts tissue
(muscle, elastic and connective) ; (b) it contracts vessels (lym-
phatics, veins and arteries); (c) it absorbs exudates; (d) it checks
secretion: (e) it stimulates; (f) it relieves pain: (g) it cleanses; (h)

158 ORIGINAL ARTICLES.

it checks hemorrhage; (i) it curtails inflammation; (j) it drains the
tractus genitalis. The utility of the vaginal douche depends on the
quantity of fluid, the degree of temperature, its composition, the
position of the patient during administration, and on systematic methods
of use.

(12) Disinfectants in a vaginal douche are secondary in value to
solvents of mucus, pus, leucocytes.

(13) The objects to accomplish by a douche are: (a) The dissolv-
ing of the elements in the discharge, as mucus, pus, and leucocytes ; (b)
the mechanical removal of morbid secretions, accumulations and foreign
bodies; (c) antisepsis; (d) diagnosis (and it includes number 11).

( 14) The requirements of a douche ; (a) It should be nonirritating ;
(b) it should be a clear solution; (c) it should possess solvent powers
of pus, and especially mucus; (d) it should be continued for months;
(e) omit the douche for four days during menstruation.

(15) A vaginal douche, administered according to the above direc-
tions, will prove to be of therapeutic value, in the treatment of pelvic
disease, a prophylactic agent, and a comfort to the patient.

( 16) The vaginal douche is contraindicated in subjects with oviduc-
tal gestation or acute pyosalpinx as it it liable to induce rupture of the
oviductal wall, abortion or leakage of pus through the abdominal
oviductal sphincter.

Ill,— VAGINAL I^AMPOiV.

( 1 ) The composition of the vaginal tampon consists of a roll of
medicated cotton (hen-egg size), tied to a twelve-inch string, placed
in a solution of sixteen ounces of glycerine and two ounces of boracic
acid.

(2) The duration of preparation of vaginal tampon should be to lie
in the boroglyceride solution forty-eight hours before using.

(3) The utility of the vaginal tampon is : (a) It is hygroscopic ; (b)
it serves as a mechanical support; (c) it contracts tissue (muscle,
elastic, connective) ; (d) it contracts vessels (lymhatics, veins and
arteries) ; (e) it hastens absorption of exudates; (f) it checks secre-
tions; (g) it stimulates; (h) it curtails inflammation; (i) it drains the
pelvic organs; (j) it cleanses; (k) it dissolves mucus, pas, and leuco-
cytes. The utility of a vaginal tampon depends on its composition, the
quantity employed, the duration of its application, and on systematic
method of use.

(5) The methods of introduction consists in placing three to five
vaginal tampons (with, or better, without a speculum) in the vaginal
fornices in the direction of least resistance.

(5a) Disinfectants in a vaginal tampon is secondary to its other
qualities, especially that of hygroscopy.

(6) The object to accomplish by a vaginal tampon is: Maximum
hygroscopy, dissolving the elements in the discharge, as mucus, pus.

TRACTUS GENITALIS. 169

leucocytes, the mechanical removal of morbid secretions, accumulation
and foreign bodies, diagonis, and mechanical support.

(7) The diagnosis is aided by the use of a tampon by collecting
and preserving the uterine discharge (as pus, blood, debris).

(8) The requirements of a vaginal tampon are: (a) It should be
nonirritating ; (b) it should possess hygroscopic power; (c) it should
be a solvent of discharges (mucous, pus, leucocytes, blood) ; (d) it
should aid in the dissolving of the mechanical removal of morbid secre-
tions, accumulations, and foreign bodies; (e) it should be aseptic (not
necessarily antiseptic) ; (f) it should not indelibly stain the clothing
(this is objection to its use as, for example, ichthyol) ; (g) it should
be reasonably economic.

(9) The frequency of application of the boroglyceride vaginal tam-
pons should be in general, twice weekly, more frequent employment
may cause irritation.

(10) The time to apply the tampon is at night during maximum
anatomic and physiologic rest.

(11) The duration the tampon may remain usefully in position is
ten to twenty-four hours.

(12) There are no special contraindications to the application of the
vaginal tampon (in pelvic disease).

(13) The boroglyceride vaginal tampon may be beneficially applied
in: (a) inflammatory pelvic disease (vaginitis, endometritis, myome-
tritis, endosalpingitis, myosalpingiti3, pelvic peritonitis, proctitis, cys-
titis) ; (b) sacropubic hernia, support for the uterus, cystocele and
rectocele) ; (c) in genital ptosis it depletes the lymphatics and veins.

(14) A vaginal tampon applied according to the above directions
will prove to be of therapeutic value in the treatment of pelvic disease,
a prophylactic agent and a comfort to the patient.

JV,—J/AB/TAT,

The value of fresh air was never realized so much as at present.
Fresh cold air cures pulmonary and other tuberculosis. The success of
the sanitarium is the continued use of fresh (cold) air. The subject
should sleep with fresh cold air passing through an open window space
of three by three feet. It appears to be demonstrated that cold fresh
air is more beneficial than warm fresh air. It is common talk among
people that one winter in the mountain is worth two summers for the
consumptive. The curative and beneficial effect of cold fresh air con-
tinually, day and night, for the family must be preached in season and
out of season by physicians. The windows should be open all night.
Fresh cold air is one of the best therapeutic agents in pathologic physi-
ology of the tractus genitalis.

Exercise is an essential for health. Muscles exercise a dominating
control over circulation (blood and lymph). The abdominal muscles
influence the caliber of the splanchnic vessels. They exercise an essen-
tial influence over the peristalsis secretion, absorption of the tractus

160 ORIGINAL ARTICLES.

intestinalis, urinarius vasculoris and genitalis. The muscles massage
the viscera, enhancing their function and the rate of circulation. In the
uterus, the most typical example, it is prominently marked how the
myometrium controls the blood currents like living ligatures. The
habitat that furnishes opportunity for abundant fresh air and ample
exercise is the one that affords the essential chances for recovery of
pathologic physiology in the tractus genitalis.

SOME MEDICAL MISTAKES.*
By miles F. porter, M. D., Fort Wayne. Indiana.

PROPRSSOR OP SURGBRY IN THB INDIANA MBOICAL COLLBGB, DBPARTMBNT OF MBDICINB OP PUKDUB

UmVBBSITY.

"To err is human, to forgive divine.'* To acknowledge error to
our brothers that they may avoid erring likewise, is manly. The man
who never makes a mistake has not yet been born. Not he who makes
mistakes, but he who makes mistakes and fails to profit by them is a
dangerous doctor. Experience teaches very largely through mistakes
used as object lessons. Medical meetings might be more profitable
were we to report more of our failures and fewer of our successes.
There should be, in the interest of our patients, a general reciprocity in
the profession in the matter of mistakes and failures as well as in the
matter of successes. When such reciprocity prevails professional
advancement will be more rapid than it is now. What appears to me
as a mistake may appear to another more capable of judging than I, to
be altogether good. Let us therefore talk and tell of the mistakes as
they appear to us, frankly and fearlessly but with tolerance, having in
mind Cromwell's admonition to the Scotch Parliament, "In the name
of God, Gentlemen, conceive it possible that you may be mistaken."
Nor must we forget that the methods we criticize today may be those
we adopt tomorrow, and that the men who now seem well-nigh impos-
sible may, as we learn to know them better, rise in our estimation until
in the end, honesty may compel us to say of them as does Tommy
Atkins (^f Gunga Din,

"Though Tve belted you and flayed you
"hy the living God that made you
You're a better man than I am, Gunga Din."

Let these discussions be impersonal when they may be, personal if they
must be, always without malice, conducted with candor and always
between ourselves. Our motto in this matter might well be, "An open
field and a fair fight," not with a view towards determining "who is the-
best man," but for the purpose of making us all better doctors.

If one with so little experience as I in pedagogy might be permitted
to speak on the subject, I would like to refer to what seems to me a
serious error in the method of teaching, which is quite prevalent in

♦Read at the Detroit meeting of the Northern Tri-State Medical Society.

SOME MEDICAL MISTAKES. 161

our medical schools. Too much effort is made to cram the student full
of facts and too much stress is laid upon the necessity of his acquiring
them, and too little time and energy is spent in teaching him to think,
to reason, to see the relationship that one fact holds to another, to the
end that if given the basic principles, he may himself deduce their
practical application. Wisdom rather than knowledge should be the
chief aim of both student and teacher.

The large clinic, as a teaching medium, is very largely a farce.
Barring the good that the student gets from the talk, and the good
which a very few who are close to the patient get from observation,
the large clinic serves no purpose worthy the energy and expense
entailed. That the large clinic is still recognized as a method of teach-
ing is due to two facts ; first, the general tendency to revere that which
is old, and second, it is a good advertising medium for the clinician,
and the institution under tne auspices of which it is held. We must
increase the number of the clinics and decrease the size of the classes.

The prevailing tendency of most students, and doctors as well, is
toward that which is practical, hence the tendency to slight the funda-
mental principles and take up the so-called practical branches before
the student is prepared for this work. This tendency might be men-
tioned as a third reason why the large clinic still flourishes. Prac-
titioners and teachers should strive to inculcate the student's mind
with the fact that a thorough mastery of the principles of medicme is
necessary before one is capable of understanding the practical branches.

The undergraduate student who pursues his studies with a view of
l)racticing a specialty after graduation makes a grievous error and the
schools who encourage this kind of work err likewise. To make a
good specialist we must first have a good general practitioner. This
entails a comprehensive study of all the branches as indicated in the
usual four years' course supplemented by, I should say, at least five
years of general practice. The young doctor who launches at once
into a specialty after getting his degree, may be a very good specialist,
comparatively, but like the man who enters upon the study of medicine
without an adequate preliminary education, he does himself an injustice,
because he cannot in this way do the best of which he is capable.

We should strive also to impress prospective medical students with
the necessity of a good education preparatory to entering upon their
professional studies. One who takes up the study of medicine with an
untrained mind does himself an injustice. He may succeed in making
of himself a splendid doctor, but he cannot achieve that success which
might have been his had he started without the handicap of an inefiicient
preliminary education. Given a good preliminary education and a
good medical education supplemented with a year's hospital training
and it w-ould seem that one should be well equipped for the practice
of his profession, but is he? Comparatively speaking, yes, but actually,
no. He finds that hospital methods and manners are not applicable in
private practice and the changes necessary are often not worked out

162 ORIGINAL ARTICLES.

under long months and sometimes years of patient and oft-times painful
toil. Because this is true, I "am not at all sure that we gained much
when we substituted clinical and hospital teaching for the didactic
lecture and the apprenticeship. A year's experience w-ith a good gen-
eral practitioner is worth more to the recent graduate in medicine than
is a year's hospital w'ork. To have both is better, but if he can have
but the one, then I would advise a year's practice under the direction
of a good doctor in general practice.

Man is a machine, and something more, he is a sentient being and
one can gain but a very incomplete knowledge of him by studying his
parts in a laboratory. This piecemeal study of the human body is
valuable, it is essential in a medical education, but it is by no means
sufficient. The doctor must study the w^hole live man, sick and sound,
well-formed and deformed. It has seemed to me that there has lately
been a tendency to slight the study of the patient himself for a study
of his tissues and secretions. The value of blood analyses, urine
analyses, cryoscopy, microscopic and bacteriologic examinations, has,
it seems to me, been overestimated while older and more reliable
methods of examination have been undervalued. I would not be mis-
understood. Chemic, microscopic and bacteriologic examinations are
valuable adjuncts in diagnosis, and we should avail ourselves of their
help, but they are seldom as dependable as are the older methods, such
as palpation, percussion, et cetera.

I have known the leucocyte count to indicate pus in an appendix
where there was no pus, and no evidences of inflammation save upon
microscopic examination, but I have never seen rigidity and tenderness
of the abdomen without peritonitis, nor peritonitis without tenderness
and rigidity. I have seen a man die in uremic convulsions within
twelve hours after a quantitative analyses of his urine showed that he
was excreting a normal amount of urea and it was declared that he
was in no danger from uremia. I have known a skiagraph to show
an ugly deformity in fractures when both the functional and cosmetic
results were perfect. On the other hand, I have seen skiagraphs that
showed perfect results when in reality there was great deformity and
much loss of function.

The microscope as an aid in the diagnosis of malignant disease is
well-nigh invaluable, but it is by no means infallible. I have known
growths pronojLinced innocent after microscopic examination to prove
themselves violently malignant, and I have known others to be pro-
nounced malignant when all other evidence was to the contrary. It is
well known that a man may be perfectly well and yet carry either
tubercle bacilH, the Klebs-Loeffler bacillus, or the pneumococcus in the
secretic^n of his mouth and throat.

Have the mo<lern methods of analysis of the stomach contents
resulted in earlier diagnosis in gastric cancer? Answering from per-
sonal experience, I should say no, and I am not aw'are that my experi-
ence along this line has been peculiar. »

SOME MEDICAL MISTAKES. 163

The natural senses unaided save by means used to make otherwise
inaccessible parts accessible, such as anesthesia specula, et cetera, are
the most reliable diagnostic means known, and the cultivation of these
senses for this use remains today as the surest and best way to the
achievement of diagnostic skill. With the creation of instruments of
precision and the development of laboratory methods has grown up a
tendency to neglect the study of the patient himself, a tendency to less
careful and painstaking observation of symptoms. Just here, too, let
me say that we are losing the art of expressing ourselves clearly and
elegantly. Would you have proof that we are less accurate observers
than our fathers in medicine and that we express ourselves less well,
procure Watson's "Practice,'' Fothergill's "Handbook of Treatment,"
and compare them with like works of the present day. To be sure, we
have gained much but we have lost also not a little. My contention
is that we may continue to gain just as rapidly at a lesser loss than
now obtains.

Measured by morbidity and mortality the costliest error and the
commonest is delay. Practically all the deaths due to appendicitis and
strangulated hernia, and more than half of those due to tuberculosis
and cancer might be prevented by prompt diagnosis and treatment.
Better remove a dozen healthy appendices than to allow one to remain
until it perforates, but there need be no necessity for doing either.
Taxis in strangulated hernia is dangerous and should be abandoned.
An early operation cures the hernia permanently and practically with-
out risk. Practically all tumors should be removed as soon as their
existence is known. This will mean the removal of many benign
tumors to be sure, but it wall also mean the removal of malignant tumors
in time to obtain a permanent cure. In this connection, too, it should
be remembered that nonmalignant tumors frequently become malignant,
so that in the end the advice to remove all tumors early will, if fol-
lowed, result in a great decrease in the mortality and morbidity due to
neoplasms.

Prostatism, that bane of old men, will have largely lost its terrors
when timely prostatectomy comes to be recognized, as it should be, as
the only correct treatment for this condition.

There is one more mistake quite prevalent to which I want to refer,
namely, unnecessary dressing and meddling with wounds. I refer to
the frequent Washings of pus cavities, the probing of sinuses, the cut-
ting away of sloughs, the curetting of recent wounds to remove foreign
matter, the removal of bone fragments, injured skin and muscles, and
the frequent removal of dressings for the purpose of inspecting a
wound. In certain cases these measures are not only permissible but
demanded, of course, but that they are instituted all too often for the
comfort and welfare of the patient I am convinced. To wash pus
cavities is usually worse than useless, loose bone fragments often
become fixed and serve a useful purpose, to cut a slough free is to
open a new avenue for infection, skin and other tissues that seem

164 ORIGINAL ARTICLES.

injured beyond repair may live, curettage of recent wounds adds insult
to injury and usually is harmful rather than beneficial, dressings prop-
erly applied should not be changed until the wound is either healed or
covered with granulations unless the conditions demand it.

For all doctors to do all things necessary as soon as the necessity
. arose, and avoid doing all things unnecessary and harmful would be
to achieve perfection. This is impossible, hence it will ever remain
onr blessed privilege to strive.

207 West Wayne Street.

TONSILLITIS AND ITS COMPLICATIONS.*
By CHARLES F. KUHN, M. D., Detroit. Michigan.

LBCrUKSR ON PHYSIOLOGY IN THE MICHIGAN COLLBGB OF MBDICINR AND SURGERY.

Much has been said of late concerning the analogy between ton-
sillitis and acute inflammatory rheumatism. It has recently fallen to
my lot to treat a number of cases in which the sequalae have been dis-
astrous, and I have been lead to regard tonsillitis as one' of the most
serious diseases we have to treat, and one which, if not properly treated,
leaves the patient in a debilitated state, susceptible to any and all
infections.

I believe the tonsil to be an abnormal gland or adenoid, and in exam-
ining several hundred throats found an entire absence of the faucial
tonsils in over half the patients, and only a rudimentary tonsil in many
others. The existence of full-sized tonsils such as are described in
works on anatomy is relatively rare, the largest being found in children
and young adults. Persons with large tonsils are invariably afflicted
with "catarrh," since being mouth-breathers in consequence of the small
nasopharynx, various microorganisms necessarily lodge in the crypts
of the tonsils. The tendency of the profession and laity to regard ton-
sillitis lightly, allowing the patient to go outdoors, attend to business,
work hard, or, if a child, to go to school, is responsible for many dam-
aged hearts, endocarditis, hypertrophy of the heart, trachycardia, otitis
media, deafness, pleuritis, mostoiditis, inflammatory rheumatism,
anemia, conjunctivitis and neurosis.

The following cases occurring in my practice, and taken from my
clinical records, convince me of the truth of the assertions made :

Case I. — A young man, nineteen years of age, machinist, previous
health good, weight one hundred forty pounds, habits of life excellent,
came to my ofiice, November 5, 1904, suffering with sore throat and
complaining of feeling sore all over. Examination showed follicular
tonsillitis. Temperature 101°, pulse 90; urinalysis showed specific
gravity T020, reaction acid, and slight amount of albumin. He was
told to return home and remain quiet until well, a diet consisting of
milk, broths, and toast being ordered. Medicinal treatment embraced

♦Read before the Detroit meeting of the Northern Tri- State Medical
Association.

TONSILLITIS AND ITS COMPLICAPIONS. 165

fifteen grains of salicylate of soda with five minims nux vomica in elixir
of pepsin, and a glass of water every three hours, together with a gargle
containing twenty-five per cent of hydrogen peroxide, four times a day.
The bowels were moved with sulphate of magnesia. On the third day
this patient went to work feeling much better, but after laboring several
hours became weak, and by noon had severe pains in the wrists. He
managed to work all day, and consulted me in the evening. Examina-
tion revealed a temperature of 102°, pulse 100, full and bounding;
wrists swollen, red and painful to the touch. The heart and chest
sounds were normal. Patient was advised to repair to bed and remain
there until well. I could not keep him in bed, however, as he claimed
he felt better when about. An erythematous eruption appeared over
his body, and the joint symptoms followed the usual course, attacking
nearly all the joints from time to time. Endocarditis and hypertrophy
followed, and, despite all that was done, he died on the sixtieth day.

Case II. — An unmarried lady, twenty years old, domestic, family
history good, previous health and habits good, consulted me complain-
ing of sore throat and pain in all the joints. Examination revealed
tonsils enlarged, and covered with a follicular exudate. Temperature
100°, pulse 90; chest and heart sounds normal. She was told to go
home and retire to bed and not get up until well. A diet of milk and
gruel was prescribed. Medicinal treatment contemplated salicylate of
soda and alkalies internally, with a gargle locally. Patient continued
her work for two days, when I called and found her in bed, suffering
intense pain in her left knee-joint. No other joints were involved.
She was taken to a hospital, where every attention was given her. An
ice-bag was placed over the heart, and medication was given according
to symptoms. Consultation was held several times, and the prognosis
was considered favorable. The pain and swelling continued in the left
knee-joint and endocarditis developed at the end of the first week, death
occurring on the fourteenth day.

Case III. — A boy, seventeen years old, laborer, appeared at my office
with an ordinary follicular tonsillitis. He had been sick for four days.
Temperature 101°, pulse 100; heart and chest normal; urine contained
albumin. I saw him at his home again the next day and found him
in great pain; temperature 104°, pulse no; dyspnea, coated tongue,
diarrhea, and cold perspiration. Pain was referred to limbs and heart.
An ice-bag was applied over the precordia; one-fortieth grain of sul-
phate of strychnine was given per orem, three times a day, with infusion
of digitalis, and twenty cubic centimeters of antistreptococcic serum
were injected daily. I saw him again at night and found his left knee-
joint enormously swollen and inflamed. Patient was seen in consulta-
tion by several physicians. The endocarditis and swelling of the left
limb continued until death, which occurred on the sixth day.

Case IV. — A married woman, twenty-four years old, housewife. I
was called to her home to attend her in confinement. Patient had
always enjoyed good health. She was in labor about twenty hours,

166 ORIGINAL ARTICLES.

and I delivered her with instruments. The perineum was lacerated
and I repaired this damage at .the time. The usual asepsis was observed
preceding and during the puerperium. On the fourth day the nurse
advised me that the patient was restless and had some fever. Exami-
nation revealed a temperature of 102'', pulse no, respiration 24.
Vaginal examination showed a membranous exudate on vulva and
cervix. This was treated locally and twenty cubic centimeters of anti-
streptococcic serum injected. Patient was examined at about 10 o'clock
that night and local treatment applied. I washed my hands in a lysol
solution as on other occasions and went home. About i o'clock I
awoke with a pain in my right index finger. I could not sleep so I
arose and found on examination a vesicle on the palmar aspect of the
finger near the tip. I had a rigor and a very restless feeling; sore all
over my body. By morning I had a typical tonsillitis and infected
finger. I was quite sick for three days, two other fingers becoming
infected, first with a vesicle, and then a pustule, which eventually
healed. No culture was taken. I have not been able to decide whether
I infected the patient, or whether she infected me. She recovered in
about one week.

Case V, — A man, twenty-two years old, bank clerk, called at my
ofiice suffering from a slight attack of tonsillitis. The usual remedies
were prescribed, and the patient advised to stay at home and keep
perfectly quiet. He told me the next morning that he felt much bet-
ter, and that as business was urgent at the bank, he thought he would
return to work. I did not hear from him for several days, when he
came to my office complaining of a pain in his head. Examination
showed a normal temperature, chest and heart. I prescribed three
grains of the sulphate of quinine and one-fourth grain of the sulphate
of codeine, to be taken every three hours. I also admonished him to
remain quiet. The next day he had temperature and severe pain in
the he^d and ear. I suspected otitis media and ordered hot dry heat
to the ear. Pain became severe and after examination I performed
peracentesis of the drum, which afforded no relief. Pressure over the
antrum and tip of the mastoid caused great pain, and mastoiditis was
diagnosed, for the relief of which an operation was performed.

Case VI. — A school girl, sixteen years old. Patient had large ser-
rated tonsils, was anemic, and suffered with frequent headaches. I
diagnosed neuralgia and suppurative tonsillitis. Tonsillectomy was
performed August 7, 1904. Her general health improved gradually
and she has been free from throat trouble, headache and neuralgia
since.

Case VII. — A school girl, fifteen years old. Patient had very large
tonsils with frequent attacks of follicular tonsillitis. She always com-
plained of severe earache during these attacks, and suffered wnth head-
ache and shortness of breath on exertion. I advised removal of tonsils,
but her parents objected. She is now seventeen years old and is nearly

TONSILLITIS AND ITS COMPLICATIONS. 167

deaf in her left ear. She also has tachycardia, the pulse rate being 140
to 150. There is a slight hypertrophy, but no murmur or exophthalmic
goiter. An interesting feature in this case is the family history. Her
father and mother are healthy. The family consists of four girls and
three boys. These children all had very large tonsils, were mouth
breathers, had nasal catarrh and were sick a great deal. The oldest
girl, aged nineteen, is anemic and subject to hysteroepileptic attacks.
The younger ones had frequent attacks of sore throat and spasms.
Four years ago I removed the tonsils of the six-year old girl and
she has been in perfect health since.

Case VIII. — A man, age twenty-eight, machinist. Patient has suf-
fered with numerous attacks of follicular tonsillitis. His tonsils are
hypertrophied and flabby. Two years ago, after an attack, he com-
])lained of tinnitus aurium, from which he is a constant sufferer.

From the above cases and others I am convinced that infection
takes place through the tonsils, and that the follicles and crypts are
the receptacles for the streptococcus, staphylococcus, Klebs-Loeffler,
tubercle bacillus and other forms of microorganisms. Upon exami-
nation we frequently find the tonsil diseased with sinuses leading into
little pockets of pus. I have examined a number of patients suffering
with endocarditis, hypertrophy of heart, pleuritis deafness and rheuma-
tism, and giving history of perfect health before an attack of sore
throat, for which they did nothing, or continued to work while taking
medicine. I believe the toxins are disseminated through the lymphatics
and blood-vessels, as the cervical and inguinal lymphatics are tender
and enlarged, and arteritis, phlebitis, and embolism occurs in the blood-
vessels. Patients suffering with tonsillitis should be warned of the
danger of going out too soon. Absolute rest is most essential and the
treatment should be thorough. The tonsils should be treated locally
with a gargle of acetezone, normal saline solution, or one of the alkaline
solutions on the market. Internal medication as indicated, and I have
a preference for salicylate of soda. Existing anemia should not be
overlooked. The tincture of chloride of iron in large doses has a good
effect. The heart, lungs, pleura, intestinal canal and kidneys should
be carefully watched. The diet should consist of milk, cereals and
vegetables, meat, coffee, tea, or alcohol l)eing prohibited. Troublesome
and enlarged tonsils should be removed, preferably with a snare, as this
prevents hemorrhage. If only a small piece is extirpated, allowing
drainage, good results follow in cases where the tonsils cannot be
enucleated. Cauterization causes scar-tissue formation which is pain-
ful and does not give satisfactory results.

That tonsillitis is a local manifestation of a general infection, having
a selective tendency to attack all the serous meml)ranes, lymphatics and
blood-vessels of the body, I am certain. I have reported the al)ove
cases rather than some terminating in uneventful recovery, with which
we are all familiar.

168 ORIGINAL ARTICLES.

TRANSACTIONS.

CLINICAL SOCIETY OF THE NEW YORK POLYCLINIC.

STATED MEETING, MARCH 5, 1906.

The President, JOHN J. MacPHEE, M. D., in the Chair. .
Reported by FREDERIC^ C. KELLER, M.D., Secretary.

READING OF PAPERS.
RENAL COLIC.

Doctor Edwwrd L. Keves, Jr., read a paper on this subject. He
said, in part: Renal colic is usually considered a symptom of kidney
stone ; but it is not absolutely pathognomic of stone nor are the position
and character of the colic pains always an infallible index of the posi-
tion of the stone. Indeed so misleading is renal colic in a certain few-
cases, and yet so rarely is it a symptom of anything but stone, that
I think it by no means waste of energy to study attentively some of the
cases which have come under my observation and in which renal colic
has been a misleading and often a confusing symptom.

The late Doctor Bryson once formulated in a tentative way the
•theory that stone in the pelvis of the kidney causes pain in the loin
radiating down the ureter, while stone at the lower end of the ureter
causes frequent and painful urination and pain in the pelvis. This
distinction holds true in the great majority of cases; yet I have seen
one case that was a striking exception to this rule, in that the only pain
suffered was from frequent and painful urination, although the patient
had but one stone, and that lay in the pelvis of his kidney.

The first patient, a lean asthmatic man, sixty-three years old, com-
l)lained of frequent urination. Sixteen years ago he applied for
insurance and was refused on account of albuminuria. He consulted
a surgeon, who stated that he had a surgical inflammation of the
kidney. Except for the passage of two calculi from thd' right kidney,
eight and five years ago respectively, and except that he had to rise
once or twice at night to empty his bladder, there were no symptoms
until aboni a year a^^o, when his urination became more frequent and
he consulted an eminent urologist who began and has since continued
treating him for chronic cystitis attributed to prostatic hypertrophy.
His symptoms have grown gradually worse.

Examination showed the right kidney to be readily palpable, some-
what large and tender ; the left kidney could just be felt, but was not
tender. The urine was hazy with pus; specific gravity 1016; albumin
one per cent by weight ; various casts of many kinds ; many red blood
cells ; a total excretion of from twenty-five to thirty ounces ; the bladder
capacity was eight and one-half ounces. The prostate was not enlarged ;
there was no residual urine. A'-ray examination revealed a shad<.Av in

CLINICAL SOCIETY. 169

the region of the right'kidney pelvis, but for various reasons the opera-
tion was postponed for eighteen months, when the patient's condition
was so unsatisfactory that it became inperative.

Upon opening the right kidney, an oxalate stone was found fitting
in the upper end of the ureter and was removed through an incision
in the kidney pelvis. The kidney itself was considerably dilated and
covered with small cysts which contained serous, bloody and sero-
purulent fluid. It was suspected, because of the nature of the symp-
toms, that there was a stone in the ureter, but careful search failed to
reveal one.

After operation, instead of passing urine constantly, as he had done
heretofore, he had to be catherized until the second day, when he began
to urinate at intervals of from two to four hours. The secretion of
urine remained low, and, finally, at the end of three and a half weeks,
the patient died from asthenia and failure of kidney function.

It is noteworthy that in this case we were able to arrive at a diag-
nosis with the aid of an A'-ray photograph, while the practitioner who
had previously treated it had failed to make the diagnosis because he
had not employed this expedient.

In contrast to the above case, in which a patient with stone suffered
from a pain that did not resemble renal colic, the second case shows
the brilliant contrast of a patient with renal colic, but without stone.

The patient, fifty-eight years of age, complained of repeated attacks
of renal colic. He never passed blood, never had any anuria or bladder
symptoms, although since the first attack he had urinated twice at night
and every three hours by day. No lumbar tenderness could be evoked
by palpation, nor was it possible to feel either kidney. X-ray photo-
graphs showed small sclerotic kidneys, but no shadow suggestive of
stone. Examination of urine showed many pus cells, no bacteria,
and but very few blood cells. Macro*scopically there was no pus. He
was given an alkaline mixture, advised to drink very freely of water
and to exercise to the limit of toleration ; and I believe that in January,
1906, he had no further renal colic.

A detailed history is omitted of a patient who suflFered from most
violent attacks of renal colic brought on by digestive causes. A
carefully restricted diet, much exercise and water, and the administra-
tion of beta-naphthol, bismuth and salol caused a cessation of these
attacks.

In further contrast to this case was one, in which the colic caused
by digestive disturbance was intestinal and not renal, although the pain
was precisely that of renal colic.

The last history of which I have record is an example of a class
of cases which I consider very important. They are relatively infre-
quent and cause objective symptoms absolutely characteristic of renal
stone; yet a careful examination will reveal the fact that they suffer
from nothing more than seminal vesiculitis.

170 ORIGINAL ARTICLES.

RKPORTS OF CASES.
PARTIAL GASTRECTOMY FOR CARCINOMA,

Doctor Joseph I. Edgerton : I wish to present this patient, a male,
forty-one years of age. His father is living and in good health at
seventy-eight; mother died of stomach trouble, probably cancer, at
fifty-eight years of age. Patient had malaria severely twenty-five years
ago, but has had no recurrences. He indulges moderately in tea, coffee,
and alcohol, and smokes regularly from fifteen to twenty cigarettes
daily. For the past thirteen years he suffered with heartburn, which
has been more constant during the past two years, during which time
he also suffered from nausea and pain in the epigastrium after eating.
During the last few months he had burning pains after eating; was
hungry all the time, but afraid to satisfy his hunger, for when he took
solid food it remained in the stomach for an hour or so, and then
was vomited. On one occasion last winter he vomited some mucus
streaked with blood. He began washing out the stomach twice a day
on October 4, and brought up greenish clumps of mucus resembling
moss. There w^as no vertigo. His bowels were constipated, and he
lost about twenty-five pounds in weight during the last few months.

On November 27, 1905, the stomach contents contained free hydro-
chloric acid ; moderate reaction ; odor butyric. A mass could be felt
over the region of the pylorus, and operation was advised and accepted
by the patient. The usual preparation of cleansing the stomach by
lavage was performed, and in the operation Mayo's technic was fol-
lowed. The abdomen was opened near the median line and the gastric
artery was doubled, ligated and divided near the cardia. The gastro-
hepatic omentum was also doubled and ligated close to the liver, leaving
most of its structure attached to the stomach. The superior pyloric
artery was treated in the same manner, and the upper inch or more
of the duodenum was freed. With the fingers as a guide beneath the
pylorus in the lesser cavity of the peritoneum, the right gastroduodenal
artery was ligated. The gastrocolic omentum was cut distal to the
glands and vessels up, to an appropriate point on the greater curvature
and the left gastroepiploic vessels were ligated. With a running suture
of catgut through the seared stump the end of the duodenum was
closed. The proximal end of the stomach was double-clamped along
the Miculicz-Hartman line, and divided with a cautery, leaving one-
(juarter inch projection. Then gastrojejunostomy was done. The
tumor was found to occupy the pyloric end of the stomach, extending
around the whole circumference. No adhesions were present. There
was a delay in finding tftle nearest point of the jejunum that could be
brought to the stomach wall and in taking great pains to suture the
opening in the mesocolon so as to prevent hernia into the lesser cavity
of the peritoneum.

His temperature at no time following the operation was above 99.6°
Fahrenheit, and there has been no vomiting since operation. He took
water in eight hours and liquid nourishment in twenty-four. His

CLINICAI- SOCIETY. 171

bowels were moved by enemas during the first week, but there was no
distention ; in fact, no more discomfort than from an ordinary explora-
tory laparotomy alone. The man has gained about twenty-five pounds
in weight and is at his regular employment again with no discomfort
whatever referred to his stomach.

CASE OF MORPHINE POISONING,

Doctor Daniel A, Sinclair : I wish to report the case of a patient
who is sixty-three years of age, weighs one hundred eighty pounds, is
five feet six inches in height, full blooded, with marked organic heart
disease. He has been coming to my office for the past two or three
years suffering from alcoholism. He is a periodic drinker, and when
first seen, two or three years ago, had been treated along the regular
lines for such a condition. He freely informed me that he had been
in the habit of receiving injections of morphine from previous doctors
and that was the only treatment that did him any good. Accordingly
one-quarter of a grain of morphine was injected, which the patient
reported at the next visit was of no benefit whatever, stating that it
was, he knew% a very small amount — nothing like what he had been
used to getting. The dose of morphine was very carefully increased
to one-half grain without any effect, and finally, at the earnest solicita-
tion of the patient and his assurances that he could stand the morphine,
the dose was increased to one grain. This injection bore out his state-
ments as to his previous experiences and "just about steadied him,"
without producing anything but a very short sleep. His subsequent
periodic sprees were treated along the same lines, from three-quarters
to one grain being used at an injection. It became so much a
matter of course to. inject this patient and see no untoward effects
whatsoever that there was no hesitation about giving him a grain of
morphine two or three times a day, according to the exigencies of the
occasion. Between the sprees the man, who was of more than average
intelligence, not only abstained from alcohol, but did not have the
slightest desire for morphine or any other drug.

The treatment detailed above was carried out until the last spree,
about a month ago. On this occasion he presented himself, intoxicated,
but retaining all his faculties, and begged for an injection of morphine,
saying that he would only be put "on the ragged edge," as he expressed
it, if he received the usual dose. He stated that he had taken as many
as three grains of morphine without any bad effects, but this statement
he afterward denied. He had a very important meeting for the next
day, and therefore was desirous of securing a good night's rest. One
and one-half grains of morphine sulphate were injected into his left
arm. In about half an hour I was called to him hurriedly, and found
him in a much stupified condition. This was about 8 p. m. ; a small
dose of cocain was injected and I left, returning about 9 o'clock, when
the patient was breathing slowly, about five or six a minute. He was
walked up and down until about 1 1 o'clock, at w^hich time his respira-
tions had diminished to one in two minutes. Up to this time there had

172 ORIGINAL ARTICLES.

been injected hypodermatically 3/5 of a grain of cocain, 4/150 of
atropine sulphate, 4/30 of strychnine and 4/100 of nitroglycerine.
He had also been given about a quart of strong, black coffee. The
situation being desperate, at the request of the man's family 1/12 of
apomorphine sulphate was injected as an emetic and was effectual in
about one-half minute. The patient went steadily into a deep coma,
became very blue and was apparently dying. Artificial respiration
and the administration of oxygen were then resorted to and the tongue
pulled forward with artery forceps. At 1 130 p. m. he began breathing
at the rate of about four a minute. About a quart of black coffee was
given as an enema and about 3 a. m. he was breathing about ten times
a minute and was conscious.

The oxygen and artificial respiration, together with the cocain,
probably saved the man's life. Two lessons should be learned from
this case : ( i ) Not to be importuned into giving any patient a large
dose of morphine, even though he is used to it ; and, (2) not to abandon
hope or relax one's efforts, even when the patient is apparently beyond
hope, as this case show^s that even in apparently fatal cases life may
be saved.

DISCUSSION.

Doctor Robert IT. M. Dawbarn : This case recalls to my mind a
case of morphine poisoning which occurred when I was interne at the
Nursery and Child's Hospital. I placed the patient on his back and
administered atropine (the first dose of which dilated the tubes) until,
from morphine poisoning, the patient developed a case of atropine
poisoning. Life was saved by artificial respiration, which was kept
up for eight hours by myself and assistant, each taking two-minute
turns. Walking the patient up and down was tried, but the exertion
seemed only to make the heart w^eaker. If I were to criticise the treat-
ment of the case under discussion, it would be the giving of depressing
narcotics, as after vomiting from an overdose of morphine the patient
usually collapses.

Doctor Maurice Packard : In a series of experiments, in which I
have been interested, which were being conducted by Doctors Bodine
and Jeffries, they were trying to find out from guinea pigs how much
morphine w^ould act as an antidote for a given injection of cocain,
acting upon the principle that cocain is a physiological antidote for
morphine. Previously atropine had been used for this purpose, but
atropine and morphine acted similarly, in that both have a tendency
to depress the smooth muscle fibres as well as secretion, while, on the
other hand, cocain stimulates the smooth muscle fibres and increases
secretion, as is shown by the druling at the mouth and the frequency
of urination. The best possible treatment, I think, is the stomach
tube. After using it once, however, it must be used every half hour,
for the mucous membrane of the stomach repeatedly secretes morphine.
With the stomach tube and the proper use of cocain, most of these
cases will end in recovery.

DIAGNOSTIC SIGNIFICANCE OF COLIC. 173

ORIGINAL ABSTRACTS.

MEDICINE.

By GEORGE DOCK, A.M., M. D., D. Sc. Ann Arbor. Michigan.

PKOPBSSOR or MBDICINB IN THB UNIVBRSITY 09 MICHIGAN.

AND

DAVID MURRAY COWIE, M. D., Ann Arbor. Michigan.

FIRST ASSISTANT IN MBDICINB IN THB UNIVBRSITY OV MICHIGAN.

HYPERTROPHIC STENOSIS OF THE PYLORUS.

Rogers (Archives of Pediatrics, March, 1906) reports a case of
hypertrophic stenosis of the pylorus in an infant of three weeks. Med-
ical treatment was persisted in until the third month, when operation
by posterior gastro-jejunostomy was performed. Patient recovered.
The symptoms of nearly complete stenosis of the pylorus in children
are very stereotyped, and in the beginning of the gastric disturbance
they are always suggestive. Any considerable amount of food in the
stomach nine hours after the last meal, as was observed in the author*s
case, especially if present on more than one occasion and accompanied
by other symptoms of obstruction, should always determine the advisa-
bility of immediate surgical interference. This case well illustrates the
hopelessness of medical treatment. Improvement from time to time
will raise the hope that operative measures may not be necessary. Such
improvement is usually deceptive. Rogers' case is the third successful
operative case reported from this country. The operation was per-
formed under ether and occupied twenty-five minutes. d. ^r. c.

SURGERY.

By frank BANGHART WaLKER, Ph. B., M. D., Detroit, Michigan.

rROVBSSOR OV SURGBRT AND OPBKATIVR SURGRRY IN THB DETROIT POSTGRADUATB SCHOOL OP MBDICINB;
ADJUNCT PROPRSSOR OP OPBl(ATIV8 SURGBRY IN THB DBTROIT COLLBG8 OP MBDICINB.

AND

CYRENUS GARRITT DARLING. M. D., Ann Arbor. Michigan.

CLINICAL PROPBSSOR OP SURGBRT IN THB UNIVBRSITY OP MICHIGAN.

THE DIACiXOSTIC SIGNIFICAX'CE OF COLIC.

In the Nezv York Medical Journal, Volume LXXXIII, Number
XII, La Roque brings out the characteristic features of colic from dif-
ferent sources and contrasts it with peritonitis.

He refers to the common inclusion of most manifestations of
abdominal pain under the term colic but thinks it should be limited to
designate spasmodic involuntary muscular contraction of the walls of
an intraabdominal viscus or canal. The commonest causes he states
are found in the gastrointestinal tract, biliary and pancreatig passages.

174 ORIGINAL ABSTRACTS.

urinary apparatus and female generative organs. They may be inci-
dent to irritative lesions as inflammation or fermentation and their
products, including gaseous distention, to obstructive lesions as foreign
bodies, invagination, torsion and constriction from without, and to
nervomuscular incoordination as in lead poisoning and certain other
intoxications.

Certain symptoms are common to all varieties of colic, as the
paroxysmal pain, its sudden onset and griping character, restlessness,
et cetera. Certain other symptoms are referable to functional or
anatomic alterations in the structure involved. In affections involving
principally the stomach the pain is referred chiefly to the epigastrium.
Colicky pain of the intestine is often most severe in the region about
the umbilicus. Diarrhea generally indicates intestinal disease, and the
intensity of it is greatest in diffuse colonic disease. In general the
darker and more intimately mixed is the blood in the feces, the
higher is its origin. The false diarrhea incident to mechanical obstruc-
tion about the ileocecal junction is scanty, mucoid, often bloody in
character, with little fecal matter and often associated with tenesmus.
Ihe spasmodic vomiting of colic is expulsive, often violent, and in
general it may be said that the intensity of vomiting varies directly
with the height of the lesion and inversely with the severity of the
diarrhea. Except in intestinal obstruction, however, vomiting is never
stercoraceous. Colic is usually the first symptom of plumbism. The
chief diagnostic features are : Constipation, flat or retracted rigid belly,
associated cramps in other muscles, slow, wiry pulse and the absence
of all signs of intraabdominal inflammation. In connection with tabes
colic may be gastrointestinal, renal, ureteral, vesical, and even rectal,
bronchial, laryngeal and other affections are not unheard of. Biliary
colic begins and is most severe in the region of the gall-bladder, from
which it radiates along the course of the intercostal nerves to the right
scapula. Pancreatic colic is not frequent. Renal or ureteral colic
begins over the region of the kidney and radiates downward and ante-
riorly. Uterine, tubal and ovarian colic are commonly combined and
often indistinguishable. Pelvic examination generally detects the
cause.

In every case of abdominal pain the phenomena of colic must be
immediately differentiated from those of peritonitis. The author has
presented the following table:

PAIN.

Colic. Peritonitis.

Less sudden onset. * !More sudden onset.

Gradually rising to maximum. May be preceded by the pain of the

Waxing and waning in intensity. primary lesion.

Paroxysmal. No spontaneous waning in intensity,

Less positively localized to a point of persistently severe, often positively

greatest intensity. localized, and unless diffuse, there

is always a point of greatest inten-
siiv.

DIAGNOSTIC SIGNIFICANCE OF COLIC. 175

DECUBITUS.

Generally doubled up, patient may lie Thighs may be flexed, but no positive

in any position. Restlessness is doubling up. Dorsal decubitus is

marked by frequent changes in po- generally assumed, and instinctive-

sition. ly maintained.

VOMITING.

May or may not occur, when present Practically always occurs, and is of

is expulsive in type. the easy type.

BOWELS.

Constipation only accidental except Constipation marked though purg^-

in intestinal obstruction and in tives in large doses may be effect-

plumbism. ive.

Purgatives are effective except in ob- Diarrhea never present except in per-

struction. itonitis arising from pelvic organs.
Diarrhea may be a part of symptom

complex.

PERISTALSIS.

Normal or exaggerated. Never exaggerated.

Absent in the segment of gut in-
volved, but in local peritonitis this
is difficult to determine.

TENDERNESS.

Cutaneous sensibility greatly cxag- Skin tenderness insignificant as com-

gerated, broad, steady, deep pres- pared with the fixed deep-seated

sure is grateful, though a vague excruciating tenderness,

deep seated tenderness of the caus-
ative lesion may be elicited.

MUSCULAR RIGIDITY.

Never positive nor continuous except Always reflex and continuous. Not

in plumbism or great distention. easily overcome by pressure. In

May be overcome by gentle, steady localized disease may be circum-

pressure, and is not confined to a scribed,
small circumscribed area.

DLM'HRAGMATIC MOBILITY.

Never impaired except by great dis- Generally reflexly diminished, espe-

tention. cially when the upper abdomen is

Movements are not generally causa- involved. Sudden eflforts, such as

tive of pain. coughing and deep breathing, are

painful.

METEORISM.

May or may not occur, not charac- Generally noted early, though in

teristic except in obstruction. many cases slight, till disease be-

comes well marked.

LEUC OCYTOSIS.

Rarely present, and never progres- May not be present, but generally ex-

sive. ists, and if nrogressive. is of diag-

nostic value.

FEVER.

May or may not exist. A sudden fever, especially if preceded by rigor, points
to peritonitis, though its absence is perfectly compatible with this disease.

176 ORIGINAL ABSTRACTS.

GYNECOLOGY,

By REUBEN PETERSON, A. B.. M. D., Ann Arbor, Michigan.

PROPBSSOR OP GTNSCOLOGT AND OBSTBTKICS IN TKB UNIVBKSITY OF MICHIGAN.

AND

CHRISTOPHER GREGG PARNALL, A. B., M. D.. Ann Arbor, Michigan.

PIRST ASSISTANT IN GTNBCOLOGT AND OBSTETRICS IN THB UNIVBRSITY OP MICHIGAN.

DU M£AT HYPOGASTRIQUE ET DE UEPISIORRAPHIE

APPLIQUfiE AU TRAITMENT DE CERTAINES FIS-

TULES UR£THRO-V6SICO-VALGINALES.

CiiENiEUX {Reviie de gynecologic et de chirurgie abdominale, Vol-
ume X, Number I) describes an operation for certain cases of urethro-
vesico-vaginal fistulae. This operation is to be used only in rare cases.,
for exceptional indications, when other procedures have failed, or
would fail if employed. In the repair of urinary fistulae the object is
to restore control. Under various circumstances this cannot be done,
for instance, in cases where the adhesions, the extent, or the location
of the fistulous opening are such that complete closure is impos-
sible, or when the sphincter of the bladder is involved so that repair of
the fistula will not cure the incontinence.

The writer reports a case in which he employed his operation. A
woman, aged twenty-six, after a difficult labor, suffered from inconti-
nence of urine. Marked leakage took place without regard to the
position assumed. ILxamination showed practically a destruction of
the cervix and the anterior vaginal wall. The borders of the extensive
fistula were indurated and adherent at the sides to the pelvic bones,
posteriorly to the remains of the uterus. The fistula was classified as
urethro-vesico-vaginal, for the whole urethra as well as the floor of
the bladder had disappeared. Such cases are extremely rare and can-
not be treated by any of the more common operative procedures.

The method used in this case was a modification of that practiced
by Maisonneuve, Baker-Brown, and Rose, and consisted in the estab-
lishment of a communication between the bladder and the rectum with
closure of the vaginal and urethral openings. The operation is done
by making two large lateral flaps consisting each of one labium majus
with the surrounding tissue. The base or pedicle of one flap lies in a
line from the anterior commissure, along the edge of the introitus, to
the center of the perineum. The base of the second flap lies well out
at the fold forming the junction of the skin of the thigh and vulva.
The first flap is now turned, raw surface outward, into the bed formed
by dissecting loose the other flap, and sutured in place. The second
flap is now shifted over the raw surface to cover it with skin. This
fla]) is now sutured to the margin of the incision which outlined the
first flap. In- this way the meatus and the vaginal orifice are securely
closed. The opening between the vagina and the rectum, which is
made before the vulvar introitus is occluded, is utilized, subsequently.

SUBSTITUTE FEEDING IN INFANTS. 177

as an avenue through which a canula with an obturator is passed to
irrigate the vesical portion of the artificial cloaca, in order to prevent
the formation of calculi. With 'proper instruction, the patient herself
will be able to carry out this procedure.

The results of the operation are not fully stated. The writer does
not discuss the possibility of ascending infection of the urinary tract
and no idea is given as to how long the patient could retain urine. A
difficulty experienced by some surgeons after similar operations is con-
traction of the edges of the artificial fistula between the vagina and the
rectum, necessitating a more extensive opening by a subsequent oper-
ation, c. G. p.

PEDIATRICS.

By ARTHUR DAVID HOLMES, M. D.,C. M., Detroit, Michigan*

SUBSTITUTE FEEDING IN INFANTS.

Sanderson Wells (Sritish Medical Journal, July 8, 1905) says
any food not conforming with the standard composition and properties
of mother's milk must be rejected. He says artificial foods as a class
are bad, and believes wet-nursing inadvisable as it is inaccurate, incon-
venient and dangerous, because we cannot exclude syphilis. The author
relies on the modification of cow*s milk and draws the following
conclusions :

(i) That mother's milk is the only proper food for infants and
should be used whenever available.

(2) That all forms of proprietary foods are bad and to be avoided.

(3) That wet-nursing is rarely permissible.

(4) That the proper substitute food for infants is some form of
modified cow's milk.

Also the following special conclusions:

(i) That the standard at which we aim in modifying cow's milk
is the child's natural food — mother's milk.

(2) That careful attention must be paid to each of the constituents — .
proteid, fat, sugar and salts.

(3) That the proteid of cow's milk is less digestible than that of
human milk and requires overdilution compared with that of the
standard.

(4) That the whole of this indigestible proteid (caseinogen) may
be removed, leaving the more easily digestible proteid (lactalbumen)
as in whey mixtures, or that the proteid content may be completely or
partially peptonized.

(5) That cow's milk diluted sufficiently to bring the proteid into
line with the standard (that is, from four per cent to 1.5 per cent) is
deficient in fat and sugar, and that these must be subsequently added.

(6) That fat may be added in the form of cream, either separated
and of standard strength, or by using gravity creams.

(7) That lactose is the proper sugar to add.

178 ORIGINAL ABSTRACTS.

(8) That cow's milk, although neutral or alkaline when drawn,
owing to its certain infection as at present obtained and to the rapid
growth of germs it allows, beccMnes acid, and that this acidity must be
neutralized by bircarbonate of soda or limewater.

(9) That human milk is sterile. From this it follows that we should
endeavor by all the means in our power to obtain a supply of sterile
cow's milk.

(10) Germs must be killed by some method. The handiest and
most generally used being heat.

To his previous conclusions he adds the following :

( 1 ) That some attempt must be made to kill germs always present
in large quantities in milk.

(2) That boiling does this most effectually and rapidly, is much
the easier method, and, in the hands of the poor, often the only method
available, but that certain injurious changes result, to be avoided if
possible.

(3) That these changes can best be avoided at 70° centigrade
(158° Fahrenheit) for half an hour (Pasteurization).

(4) That all infant's food should therefore undergo this process
when possible.

ORTHOPEDICS.

By IRA DEAN LOREE, M.D., Ann Arbor, Michigan.

FIRST ASSISTANT IN SUKGBRY IN THE UNIVBKSITY OF MICHIGAN.

CONGENITAL COXA VARA.

Henry O. Feiss, M. D., of Cleveland, in Jamaj February 24, 1906.

He gives the history of one case with arguments favoring its origin
as intrauterine. The article contains a summary of certain experiments
performed upon the dead fetus. These consisted in fixing the limbs
in certain positions that might be assumed before birth and then noting
the relations of the parts by means of the radiograph.

He concludes that the deformity comes most commonly with defects
of the femur of the lower limbs. That it may be intrauterine in its
strictest sense, from intrauterine infection or combined with congenital
rachitic deformities.

LARYNGOLOGY.

By WILLIS SIDNEY ANDERSON, M. D., Detroit, Michigan.

ASSISTANT TO THB CHAIR OF LARYNGOLOGY IN THB DETROIT COLLEGE OF MEDICINE.

A CONTRIBUTION TO THE STUDY OF THE ETIOLOGY
OF NASAL OBSTRUCTION.
WiLHELM RoTH (Rcvue Hebdomodoire de Laryngologie, d'Otolo-
gie et de Rhinologie, January 20, 1906) calls attention to those cases
where the antrum of Highmore is involved, and where the secretion
is of such consistence that none of it flows out into the nasal fossa.

SPHINCTER AND FISSURE. 179

Examination of the nose shows no secretion, nor the usual evidence
of sinus involvement. These cases are accompanied by nasal obstruc-
tion of the side corresponding to the sinus involved. The swelling in
the nose involves the cavernous tissue, and it promptly shrinks after
the application of cocain. No anatomical reason can be found to
account for the nasal obstruction. If the antrum be thoroughly
washed out, the nasal obstruction will promptly disappear. If the
secretions are again allowed to accumulate in the sinus, the nasal
obstruction will recur. The author believes that the cause of the
swelling of the cavernous tissue is the reflex vasomotor irritation due
to the accumulation of the secretion in the sinus. Roth holds that this
type of sinus disease is an important factor in the etiology of unilateral
nasal obstruction, where no anatomical cause can be found to account
for the nasal condition.

PROCTOLOGY.

By LOUIS JACOB HIRSCHMAN, M. D., Detroit, Michigan.

CLINICAL PROVKSSOR OV PROCTOLOGY IN THB DBTROIT COLLBCR OP MRDICINB.

DIVULSION OF THE SPHINCTER, AND FISSURE IN ANI.

DwiGHT H. Murray^ under the caption, "Some Minor Rectal
Lesions," treats of a number of ano-rectal conditions, in the Buffalo
Medical Journal, Volume LXI, Number. IX.

Speaking of divulsion of the sphincter muscle, he judges, from the
statements of many physicians and patients with whom he has come in
contact, that that procedure is not well understood. At least ten min-
utes, on an average, should be occupied in this procedure. The muscle
should be carefully and slowly tired out, or paralyzed, not quickly
stretched and the muscular fibers torn. Murray has had patients who
gave a history of rapid dilation of the sphincter, which resulted in a
partial loss of sphincteric control. Rectal operations done after a proper
divulsion cause much less pain, and a soreness only is complained of in
most cases.

Fissure in ani, at the onset is indicated by a sharp cutting, tearing or
burning pain coming on during or after a bowel movement. Patients
do not always know just the time it began ; they may first notice a little
bleeding after stool, sphincteric spasm, and an increased constipation
caused by fear of pain. The stool then may become dry and hard,
making the fissure worse. These patients are in a very nervous condi-
tion with many direct and reflex symptoms. Sometimes the only symp-
tom of an anal fissure is a pain in the heel, which is often treated for
rheumatism.

Recent fissures, if there is no spasm of the sphincters or induration,
may be successfully treated without operation. Orthoform applied to
its base, followed by pure ichthyol applied every other day, is an excel-
lent treatment for most nonoperative cases. Uncomplicated cases are

180 EDITORIAL COMMENT.

cured under this treatment in from two to four weeks. Operation is
indicated in cases with hypertrophied, hard, spasmodically contracted
sphincter, and a sentinel pile well developed. Dilation, incision and
excision are the operative procedures, and their names are self-
explanatory.

EDITORIAL COMMENT.

MEDICAL CLASSICS IN MEDICAL MEETING.
Notwithstanding the important position which medical literature
occupies in the domain of medicine, students are taught practically
nothing in medical college regarding the classic works which reach
across the centuries of medical history and chronicle the representative
thought and practice of the various periods, while physicians are seldom
afforded opportunity for bibliographic research in medical meeting.
Owing to the factor of time in the career of the average practitioner,
there is doubtful possibility of acquiring extensive concrete knowledge
concerning the glories of the guild until the curriculum of every medical
college includes a course in the history of medicine. The subject
receives considerable attention in Europe, but probably not more than
a half dozen American colleges impart instruction of this nature.

* * *

A feature of the Ann Arbor meeting of the First Councilor District
Medical Society of Michigan was an exhibit by Doctor George Dock of
some representative medical books from his private library. Lack of
space determined the number of volumes shown to a certain extent,
and the works selected were chosen to represent important phases of
medical history especially in the modern period and after the rise of
pathologic anatomy. The volumes were arranged as given below, so
as to follow an order partly chronologic, partly topical. They were
open to show important or interesting passages, and each volume bore
a card with the author's name, dates and other particulars, as in the
list below, taken from these cards. The exhibit gave a bird's-eye view
of some of the most interesting periods of medical history. Some of
the books, as the "Rosa anglica" and the *'Auenbrugger," are exceed-
ingly rare.

sK sK •

John of Gaddesden, also called Johannes Anglicus. Died about

1350.

The "Doctor of Physic" of the "Canterbury Pilgrimage"; Court
Physician.

A copy of his "Rosa anglica," a compend of medicine. This is the
Venice 1902 edition, erroneously called the 15 16 edition. The first
edition was printed in 1492.

The contents give a good idea of the medicine of six hundred years

MEDICAL CLASSICS. 181

ago. The mdrk shows the celebrated passage regarding the use of red
light in smallpox.

Translation from the section on "Treatment ('Cura') of Variola:"
"Let scarlet be taken and let him who is suffering smallpox be entirely
wrapped in it or in some other red cloth. Thus I did when the son pf
the illustrious King of England suffered from the smallpox. I took
care that everything about the couch should be red and his cure was
perfectly effected, for he was restored to health, without a trace of the
pocks."

Glisson, Francis. 1597-1677. (Described Glisson's capsule.)
The first edition (1650) of his work on "Rickets," the first mono-
graph on disease published in England, except that of Caius (died
1563) on "Sweating Sickness," a much less thorough work. One of
the glories of English medicine. To Glisson's description of the mor-
bid anatomy as observed by the naked eye, subsequent writers have
added little.

BONETUS, ThEOPHIL. 162O-1689.

The first (1679) edition of the "Sepulchretum anatomicum," the
brilliant beginning of pathologic anatomy, a storehouse of the most
important observations recorded up to that time.

Mueller, Johannes. 1801-1885.

"Ueber den feineren Bau und die Formen der krankhaften Gesch-
wuelste." 1850.

This work is all Mueller finished of a projected treatise on the
"Histology and Classification of Tumors." It represents the first
fruitful application of the microscope to the study of pathologic
anatomy. One of the only two unfinished works left by this great
genius, the master of Virchow, Helmholtz, DuBois Reymond, and the
most important figure in the history of nineteenth century medicine.

"Die Medicine Reform.''

Founded by Virchow and Leubuscher July, 1848, with the object of
hastening reforms in university education; medical education and
organization; care of the sick and the poor; administration of hospi-
tals; the appointment of a Minister of Medicine for Prussia was
demanded, and a Ministry of Public Health and Medical Laws for all
Germany. "A Reform of Science and of Society." The journal was
given up at the end of one year on account of the failure of the revolu-
tion and the impossibility of a reorganization of public health, medical
education, and the medical profession.

Virchow, Rudolph. 1821-1902.

First edition of the "Cellular Pathologic."

Showing the relations of pathology and medicine to the cell doc-
trine, and the intimate changes in the tissues and organs, on which the
whole of modern medicine is based. No one before Virchow expressed
the belief that the phenomena of disease, like other biologic phenomena,
are the expressions of cellular activity, a belief that only becomes
strengthened by the advance of knowledge.

182 EDITORIAL COMMENT.

First volume of the work on "Tumors," published in three volumes
in 1863.

The first scientific work on tumors. Based on a histogenetic classi-
fication, it includes an exhaustive analysis of the older and even oldest
literature, and an almost incredible investigation of actual specimens,
macro- and microscopically. While some of the views have been
shown by later methods to be erroneous, the work still includes many
statements that reappear even now as new discoveries. It marked an
epoch and will long be used as a work of reference for all points not
requiring recent technical methods for,, their elucidation.

Senac, Jean B. 1693-1770.

"Traite de la Structure du Coeur, de son Action, et cetera," 1749.

One of the most important landmarks in the history of diseases of
the heart; especially valuable for pathologic anatomy and symptoma-
tology. Senac was one of the most distinguished French physicians of
the eighteenth century.

AUENBRUGGER, LEOPOLD. I722-1809.

First edition of the "Inventum novum," 1761, the first work on
"Percussion."

BicHAT, Xavier. 1771-1802.

The first edition of the celebrated "Anatomie generale," in which
histology, normal as well as pathologic, was first systematically studied.
As Corvisart wrote to Napoleon, announcing Bichat's death — "No one
before him has done so much and all so well and perfectly, in so short a
time."

Corvisart, J. N. 1755-1821.

Commentaries and Translation of Auenbrugger's work on "Per-
cussion." The first edition was printed in 1808. It saved Auenbrug-
ger from oblivion and forced his work on the attention of men before
auscultation was discovered.

"Diseases of the Heart," 1806. An important book, but less so
than if Corvisart had written it himself.- It was made up from his lec-
tures. This, with his "Commentaries on Auenbrugger" would have
immortalized him had he done nothing else. He was the first of the,
modern physicians ; founder of the brilliant French school in the early
part of the nineteenth century; first professor of medicine in the
Medical Clinic in Paris, 1795 ; one of the founders of modem patho-
logic anatomy ; physician to Napoleon.

Laennec, Rene-Theophile-Hippolyte. 1781-1826.

First edition of the "Mediate Auscultation."

In this Laennec followed an analytic method, describing in connec-
tion with each sign the anatomic lesion indicated. It is the outcome
of "one of the purest and most individual discoveries ever made in the
history of science." — (Benjamin Ward Richardson.)

Laennec.

Second edition, the final one by his own hands. In this, an entirely
new work, he followed a synthetic method, with descriptions of disease

MEDICAL CLASSICS. 183

that proved the vast industry and talent of the author. It is a book of
pathol(^y, as well as diagnosis, a complete treatise on diseases of the
heart and lungs, useful even at the present day. Even the treatment,
the weakest part, is far in advance of its time.

Laennec.

Showing the author's account of the discovery of mediate auscul-
tation. (Ramadge's English edition.)

PiORRY, P. A. 1794-1879.

First edition (1828) of Piorry's work on "Mediate Percussion," in
which the first advance was made in that art since the time of Auen-
brugger, namely, the use of the pleximeter. In this, and still more in
later works, Piorry was led astray by a search for refinements in exact
percussion that were only slowly overcome by the work of Skoda.

Skoda, Joseph. 1805-1881.

First edition (1839) of the "Abhandlung ucber Perkussion und
Auskultation."

In this epoch-making work Skoda turned from the ultraexact
methods of the French, who aimed at discovering specific signs for each
disease, and laid the foundation of modern physical diagnosis, in which
signs indicate physical conditions, which must be interpreted by the
revelations of pathologic anatomy. Like Auenbrugger, Skoda was
long neglected by his fellow-countrymen. The copy shown was bought
uncut. Later, many editions were published, some of them large ones,
and translations in several languages.

Louis, P. C. A. 1787-1872.

The first edition (1825) of the great work on "Phthisis." An
unsurpassed masterpiece, said to be "the most profound exposition of
the natural'history of a chronic disease of which the literature of any
age or country can boast." The first work on tuberculosis in which
the whole condition of the patient was thoroughly examined; before
that many organs and functions in the tuberculous were never studied.

Gerhard, William W. 1809-1872.

"Lectures on Diseases of the Chest." 1842.

Gerhard was a pupil of Louis, and was considered the most distin-
guished American who studied in Paris between 1830 and 1840. The
first who distinguished clearly between typhoid and typhus fevers
(article published in The American Journal of the Medical Sciences,
1835). The book shown is his principal work. Diseases of the lungs
and the pericardium are especially well done. The treatment of pneu-
monia is the old-fashioned one — ^bleeding, tartar emetic, et cetera.

BowDiTCH, Henry I. 1808-1892.

The "Young Stethoscopist" (1846) is a fine example of the work
done by the American pupils of Louis.

Jenner, Edward. 1749-1823.

The second edition of the "Inquiry" into the causes and effects of
the Variolae Vaccinae (1800), an exact reprint of the first or 1798
edition.

184 EDITORIAL COMMENT.

"No book SO small has ever been talked about so much ; no book has
been read from the original so little; no book of such dimensions has
made the name of any author so famous ; no book has been so much
praised at second hand." Jenner transformed a local into a universal
belief.

Latin translation of Jenner's first three works into Latin, made by
Aloisius Careno, published in Vienna in 1799. An important factor
in the dissemination of a knowledge of Jenner's discovery.

Waterhouse, Benjamin. 1754- 1846.

"A Prospect of Exterminating the Smallpox," 1802.

Professor of Medicine in the Cambridge (afterwards, Harvard)
Medical School. Introduced vaccination (1800) into the United
States, assisted its use by his writings and by enlisting the interest of
President Jefferson. Was called the "J^^i^^r <^f the New World."
The copy of his book shown was given to the father of Oliver Wendell
Holmes by Waterhouse, and later belonged to the Autocrat. It bears
his book-plate.

Thomson, John. 1765-1846.

In this "Account of the Varioloid Epidemic," published in 1820, the
author, considered the most learned physician in Scotland, demon-
strated the identity of smallpox and varioloid, and showed that the
latter could occur in those who had had smallpox, or had been vacci-
nated, as well as in those who had never passed through the other dis-
eases. He showed the unity of several varieties of variolous disease,
and thought that chickenpox also was merely a variety of smallpox.

Carey, Mathevv. 1760- 1839.

"Account of the Malignant [Yellow] Fever," in Philadelphia. A
classic of the first rank. It was written in two weeks and went through
four editions: November 13, November 23, November 30, 1793, and
January 16, 1794. Almost equal to DeFoe's account of the plague in
London, but Carey's work was written in the same season, while
DeFoe's was composed long after the plague, of which he saw little
or nothing.

Webster, Noah. 1758-1843.

"A Collection of Papers on the Subject of Bilious Fevers, et cetera."

The lexicographer got out this collection of reports by physicians,
with comments, in 1896, before his more celebrated work on "Epidemic
Diseases." It is chiefly interesting now in the light it throws on the
manners and customs of the time.

Drake, Daniel. 1785-1852.

Equally eminent as patriot, philanthropist and medical author.
The book on "Diseases of the Mississippi Valley" is unrivalled in the
amount and variety of its material, and is equally remarkable for the
charm of its style, the volume of information on diseases and their
treatment in a time and place unique in the history of the world, and
the glimpses of a civilization that must always be interesting to
Americans. The Committee on Medical Literature of the American

►

MEDICAL CLASSICS. 186

Medical Association, in 1850, predicted that it would probably come to
be regarded as the most valuable original work yet published in
America.

Blackall, John. 1771-1860.

In his "Observations on the Nature and Cure of Dropsies," first
published in London (1813), Blackall showed the association of dropsy
with albuminuria, the most important contribution to renal pathology
before the work of Bright. (Albumin had been discovered in urine,
in 1750, by Cotunius.)

Bright, Richard. 1789- 1858.

In this volume of his "Reports of Medical Cases" (1827) Bright
showed that in some cases of dropsy with albuminuria a peculiar alter-
ation of the kidney was present. Next to Laennec's discoveries in
thoracic disease this was perhaps the most important . discovery made
in medicine in the first half of the nineteenth century. Before Bright's
time examination of the kidneys was not regularly made at autopsies.

Beaumont, William. November 21, 1785 — ^April 25, 1853.

The first edition of the great work on "Experiments and Observa-
tions on the Gastric Juice and the Physiology of Digestion," Pittsburgh,
1833. Open to show one of the illustrations of the opening into the
stomach of Alexis Saint Martin.

Danielssen, D. C. and Boeck, W.

"Traite de la Spedalskhed ou Elephantiasis des Grecs," 1848.

The accurate scientific knowledge of leprosy began with this cele-
brated work published at the expense of the Norwegian government
and based on examinations of leper foci in all parts of Europe at a
time when many famous physicians believed leprosy to be extinct.

HuxHAM^ John. 1692-1768.

A translation of the Latin edition of 1752, published in 1758 or
1759, of the "Observations on Air and Epedemic Disease." Open at
the celebrated account of "Slow Nervous Fever," one of the earliest
recognizable descriptions of typhoid. He was the inventor of Hux-
ham's Tincture of Cinchona (Comp.)

Petit and Serres.

In the "Traite de la Fievre Entero-mesenterique" (1813), Petit
and Serres showed the constant presence of characteristic lesions in the
lower part of the ileum and in the mesenteric glands; described the
course of the lesions ; asserted they were the cause and not the effect
of the fever and that the process was due to the introduction of a for-
eign material.

Louis' work on "Typhoid Fever."

The second (1841) edition, in which the final touches were given to
the determination of typhoid fever, the work of the American pupils of
Louis being acknowledged.

Smith, Nathan. 1762-1830.

Founder and for many years faculty (sic!) of Dartmouth Medical
College ; Professor of Medicine at Yale.

186 EDITORIAL COMMENT.

His "Essay on Typhous Fever" is "like a fresh breeze from the sea
amid the dreary writing of most of his contemporaries. Never before
had the symptoms of typhoid fever been so clearly and accurately pic-
tured."—(Welch). "It does not follow," says the author, "that a
patient should take medicine because he has the disease."

Bartlett, Elisha. 1804-1855.

"History, Diagnosis, and Treatment of Typhoid and Typhus
Fever," 1842.

"One of the most notable of contributions of American physicians
to the subject. * * * written with great clearness, in logical order,
he shows in every page an accurate acquaintance with .the literature of
the day, and a knowledge also of that best of books, the book of nature.
* * * One of the most successful medical works issued." — (Osier) .

Macculloch, John. 1773-1835.

Physician, geologist, et cetera. American reprint of the "Essay
on Malaria," first published in 1827.

In this work the term malaria was first introduced into medical lit-
erature, and both its use and abuse, the latter not yet extinct as a cover
for diagnostic ignorance, began then. The word had long been in
popular use in Italy, and was occasionally applied by nonmedical
English writers before Macculloch, as: Horace Walpole, 1740; Char-
lotte Smith, 1801 ; J. Forsyth, 1813; Byron, 1821.

CuRRiE, James. 1756-1805.

Copy of the "Medical Reports on the Effects of Water," first pub-
lished in 1797. Currie sought to establish three rules of practice in
the treatment of fevers : ( i ) In the early stages cold water should be
poured over the body. (2) In the later stages the patient should be
bathed in tepid water. (3) In all stages abundant potations of cold
water were recommended. This was the first large series of medical
observations in which clinical thermometry was systematically used.

WUNDERLICH, C. A. 1815-1877.

"Das Verhalten der Eigenwarme in Krankheiten." (Second edition,
1870).

The first systematic study of clinical thermometry. Little has been
added to it and still less changed. Scattered observations on body
temperature were made from the time of Sanctorius (died 1636),
especially by Boerhaave, de Haen (who showed that the temperature
is elevated in the cold stage of fevers, and in chills), John Hunter,
James Currie and by others. Wunderlich was the first to get accurate
and frequent readings of the temperature, and the book is based on
the study of twenty-five thousand cases and many millions of single
observations.

Brand, Ernst.

"Die Wasserbehandlung der typhoesen Fieber."

The second (1877) edition of the work that led to the modem
treatment of typhoid fever by the cold bath.

ANESTHESIA BY SCOFOLAMIN-MORPHIN 187

ANNOTATIONS.

A DISCOVERY REGARDING DEAD TUBERCLE BACILLI.

The experiments of Calmette and Breton with tubercle bacilli killed
by heat demonstrate that repeated ingestion of the organisms hastens
the death of tuberculous subjects in similar manner as does the con-
tinuous employment of minute doses of tuberculin. The discovery is a
powerful argument against the use of milk obtained from animals
which manifest even the remotest tendency toward tuberculosis. While
the results of ingestion of dead tuberculous material are more delete-
rious to consumptives, normal persons are by no means immune to its
action. The authors conclude that under no circumstances should the
milk of tuberculous animals, even though sterilized, be consumed by
persons afflicted with consumption.

THE CATASTROPHE ON THE COAST. *

On the morning of April i8, San Francisco was visited by a
frightful disaster which laid the beautiful city in ruins and rendered
thousands of people destitute and homeless. Possibly no siesmic dis-
turbance ever wreaked such complete distruction on the Western
Hemisphere, and, although the list of dead, which is comparatively
small, has probably been overestimated, the bodily ills which are
destined to result from earthquake and holocaust will doubtless visit
a large proportion of the population, while the number of fatalities
indirectly attributable to the catastrophe cannot be predicted. Many
women endured the ordeal of childbirth unassisted by medical attend-
ance, and scores of premature births, precipitated by fright and expos-
ure, are reported. Physicians, hampered by entire loss of medical
equipment, labored heroically to aid suffering humanity, but with the
dearth of food and clothing, their efforts were almost futile, and
undoubtedly many perished before a food supply could be established.
The country has responded grandly to the calls for monetary assist-
ance— a sum of magnitudinous proportions having already been con-
tributed, and if the rise of other devastated cities may be taken as a
criterion San Francisco will shortly regain its condition of hygienic
and esthetic equilibrium.

SURGICAL ANESTHESIA BY SCOPOLAMIN-MORPHIN.

While the results obtained in the domain of anesthesia have been
varied, the operator has demonstrated wonderful achievements with
the agents at present utilized to produce insensibility. However, the
success of surgeons who have tested scopolamin-morphin anesthesia,
the ease of its administration, and the cheapness of the products

188 MEDICAL NEWS.

bespeak the possible substitution of this anesthetic for chloroform
and ether in the majority of operative cases. Scopolamin is obtained
from Scapolia Japonica by extraction, having been first isolated by
Schmidt in 1890, and first used to produce anesthesia by Schneiderlin
about five years ago. The combination is employed by hypodermically
injecting one-sixty- fourth of a grain of scopolamin hydrobrcmiate and
one-sixth of a grain of morphin sulphate in fifteen minims of distilled
water, four hours, two hours, and one hour before commencing the
operation. Following the initial injection drowsiness ensues, and the
second injection produces quite profound sleep. A third injection is
sufficient to effect complete anesthesia for several hours, during which
time the face is considerably flushed, the pulse slightly accelerated,
respiration slow, and the skin dry and warm. While the subject may
be aroused by loud talking or shaking, there is, during the period of
wakefulness, -absolute insensibility to pain. In obstetric practice this
anesthetic is pronounced free from danger to either mother or child
and there is no report of interference with contractions or modification
of hemorrhage. The placidity with which the injection is tolerated
and its freedom from symptoms of vomiting, as well as thirst, together
with other advantages already mentioned, render the medicament a
possible succedaneum to prevalent means for effecting anesthesia.

MEDICAL NEWS.

ANN ARBOR MEETING OF NURSES' ASSOCIATION.

The Michigan State Nurses' Association held its second annual
meeting in Sarah Caswell Angell Hall, April 4, 5 and 6, 1906. James
B. Angell, LL. D., president of the University of Michigan, delivered
the address of welcome, and Doctor Beverly D, Harison, secretary of
the Michigan State Board of Registration in Medicine, discoursed on
the "State Registration of Nurses." Doctor Victor C. Vaughan, dean
of the medical department of the University, contributed a paper on
"Tuberculosis," while "A Neglected Field of Nursing — the County
Almshouse," received attention from Mrs. Caroline Bartlett Crane.
Doctor C. B. G. de Nancrede, professor of Surgery in the University,
contributed a clinic at the hospital, which was well attended by the
nurses. The social feature of the meeting contemplated a compli-
mentary concert tendered by the faculty of the University School of
Music, under the direction of Professor Albert A. Stanley, and a
reception in Barbour Gymnasium given by the graduate nurses of Ann
Arbor. The meeting was pronounced a profitable and pleasureable
affair. The following officers were elected for the ensuing year:
President, Miss Sarah E. Sly, Birmingham; first vicepresident, Mrs.
L. E. Gretter, Harper Hospital, Detroit; second vicepresident. Miss

THE DEMISE OF DOCTOR DOREMUS. 189

E. L. Parker, State School for the Blind, Lansing; treasurer. Miss
Anna M. Coleman, Saginaw General Hpspital, Saginaw; recording
secretary, Miss Agnes Deans, Detroit; corresponding secretary, Miss
Katherine Gifford, Grand Rapids.

THE DEMISE OF DOCTOR DOREMUS.

Robert Ogden Doremus^ A. M., M. D., LL. D., of New York,
died on March 22, 1906. Gotham was his native city, and at the corner
of Broadway and Cortlandt street he first saw light in 1842. His father
was one of the founders of the University of the City of New York, and
from that institution the son was graduated both in arts and medicine.
He began his medical career as assistant to Doctor John W. Draper in the
Chemical Laboratory of the University Medical School. Later he spent
considerable time studying chemistry and electrometallurgy in Paris. In
1848 he was appointed professor of chemistry in the New York College
of Pharmacy, the laboratory of which institution he equipped con-
jointly with Charles Townsend Harris. Doctor Doremus was one of
the founders of the New York Medical College, of the Long Island
College Hospital, and of Bellevue Hospital Medical College, in all of
which he filled the chair of chemistry. From 1853 to 1861 he was pro-
fessor of natural history at the Free Academy (now the College of the
City of New York), and later was appointed to the chair of chemistry
and physics in the same institution. Through his endeavor the labora-
tory at Twenty-third street and Lexington avenue became a noted
center of study, particularly with regard to electricity. He was the
first toxicologic expert to be called in a murder case in New York — the
trial of James Stephens for poisoning his wife, and his services led to
improvements in the conduct of autopsies for the courts. For many
years he was a well-known expert in criminal cases, and he is num-
bered among the first of the presidents of the Medicolegal Society. He
was a member of the New York Medical Advisory Board, and assisted
in the organization of the Municipal Department of Health, and the
establishment of the Bureau of Chemistry conducted in connection
therewith. In 1871 he was appointed president of a board for the
examination of druggists for licenses to practice pharmacy.' He inaugu-
rated the chlorine system of disinfecting ships, and thus obviated the
necessity for prolonged detentions at quarantine. The important inven-
tion of granulated, compressed gunpowder contemplates another of
his achievements. This product was employed by the French in the
Franco-Prussian War, its power greatly exceeding that of ordinary
gunpowder. The excavation of Mont Cenis tunnel was also wrought
by. this product. Doctor Doremus was interested in every department
of culture, and was especially prominent in musical circles, being one
of the founders of the Philharmonic Society, of which he likewise
officiated as president for some time. Several years ago he celebrated
his golden wedding, but since then his wife has died, and four children
survive him, Professor Charles A. Doremus being the oldest.

190 MEDICAL NEWS.

MINOR INTELLIGENCE.

An epidemic of smallpox is threatened in the penitentiary located
at Lansing, Kansas, four convicts having recently been stricken with
the disease.

The establishment of a state tuberculosis sanatorium in Iowa has
been facilitated by the passage of a bill in the legislature appropriating
$50,000 for the purpose.

At the recent Pittsburg meeting of the American Association of
Medical Colleges, the medical department of Oklahoma University
was admitted to membership.

Typhoid fever is epidemic in Pittsburg, more than four hundred
cases having thus far been admitted to the hospitals, besides the hun-
dreds of other cases scattered throughout the city.

The sum of $50,000 has been provided by Mrs. Louisa N. BuUard
for the establishment of a Chair of Neuropathology at Harvard
University. The bequest is made as a memorial to the husband of
the donor, William Story Bullard.

Saint Luke's Hospital, New York, has been enriched to the
extent of $15,000 by a bequest of Mrs. Sarah A. Sands, whose death
occurred recently. The sum will be utilized to endow three beds in
memory of the donor's husband, Abraham B. Sands.

The Prussian Minister of Railways has inaugurated a novelty in
the method of transporting sick persons in railway coaches. Suitable
stretchers will be admitted to third-class compartments, two third-class
fares being paid for patient and stretcher and one for the attendant.

Experiments announced from the Edinburgh University research
laboratory are to the effect that trypsin injected into a cancerous mass
will effect its absorption, but since the agent has only been employed
on rodents, its practical value in human subjects remains undetermined.

Doctor Johann Flintermann was recently tendered a testimonial
dinner by the Detroit Club in commemoration of the fortieth anniver-
sary of his advent into medical practice. Doctor Flintermann received
his medical degree from the University of Gottingen in 1864, and two
years later he located in Detroit.

A FREE tuberculosis clinic, to be in charge of Doctor Victor C.
Vaughan, was recently opened in the Detroit Board of Health building.
It is estimated 'that there is an average of one death a day in Detroit
from this disease, and the purpose of the clinic is to instruct subjects
how to care for themselves and prevent the spread of contagion.

Doctor Frank William Smithies has been appointed demon-
strator of medicine in the University of Michigan, to succeed Doctor
Roger S. Morris, who accepted a position in Johns Hopkins Hospital.
Doctor Smithies is an Ann Arbor graduate, and since receiving his
degree has been connected in a teaching capacity with the University
of Chicago.

EPITOME OF THE PRACTICE OF MEDICINE. 191

Fourteen women physicians of Detroit recently organized a society
whose membership is limited exclusively to women practitioners. It
is designated the Women's Academy of Medicine, and is the third of
its kind in the country, the others being located at New York City and
Rochester, New York. Women physicians in Michigan who are mem-
bers of their county society are eligible to membership in the new
guild. The following officers were elected for the ensuing year:
President, Doctor Lucy J. Utter; vicepresident. Doctor Mary G.
Haskins; secretary. Doctor Anna Starring; treasurer. Doctor Minta
P. Kemp; councilors, Doctors Florence Huson, Louise Rosenthal-
Thompson and Isabella Holdom.

On April 2 a free clinic, to be known as the German Polyclinic,
was established in connection with Grace Hospital, Detroit. The new
institution will be essentially German in character, none but physicians
of Teutonic extraction being eligible for official positions, although
treatment will be tendered to afflicted regardless of race or creed.
Doctors Herman Kiefer and Ernest W. Haas have been elevated
respectively to the presidency and secretaryship, and the various chairs
will be occupied as follows: Children's diseases, Doctors Charles G.
Jennings and Guy L. Kiefer ; general medicine : attending staff. Doctors
Ernest W. Haas and August Gorenflo; consulting staff, Doctors Carl
Bonning and Herman Kiefer; diseases of the eye and ear, Doctor
Louis J. Hirschman ; diseases of women. Doctor James A. MacMillan ;
nose and throat, Doctor Fred J. Clippert; diseases of the digestive
organs. Doctor George W. Wagner; pathologist, Doctor Edward H.
Hay ward; surgery. Doctors Johnston B. Kennedy and George H.
Palmerlee.

RECENT LITERATURE-

REVIEWS.

EPITOME OF THE PRACTICE OF MEDICINE.*
This little manual is indeed an excellent guide so far as it goes. It
is intended to be only an epitome. There are men who oppose the use of
these contractions — good men; and there are men who think they are
of great use to the student and practitioner who are also good men.
These compendiums cannot help being good books because they are
copied from good books. Usually they are condensed rearrangements
of Osier's, Anders', or some other standard work, altered just enough
to make the reading a little different, with the definitions a bit modified.
Even those who oppose them enjoy perusing them. They are some-
times refreshing, and if one should question closely he will probably

192 RECENT LITERATURE.

find that these men are fond of some similar little book, the only differ-
ence being that it is published in another language. We find a few
mistakes but they can easily be excused on the ground of "first edition."
We think that many of these abbreviated books have a place, and many
of them fill a long felt want. This is one of them. Jt is thoroughly
up-to-date.

*A Manual for Students and Practitioners. By Hughes Dayton,
M. D., Principal to the Class in Medicine, New York Hospital, Out-
Patient Department; Clinical Assistant in Medicine, Vanderbilt Clinic,
College of Physicians and Surgeons, Columbia University. In one
i2mo volume of 324 pages. Cloth, $1.00, net. Lea Brothers & Com-
pany, Publishers, Philadelphia and New York, 1905.

A LABORATORY MANUAL OF PHYSIOLOGICAL
CHEMISTRY.*

Doctor Rockwood's laboratory manual is admirably adapted to the
needs of the student of physiological chemistry. Only the most impor-
tant illustrative experiments are given in large type and they are not
too many and are well chosen. It has the advantage over books that
are filled with interrogations in that while it does not fail to interrogate,
it intelligently answers, thus making it of service to the student and of
inestimable value to the busy physician who wants an immediate reply
to his query. Here and there are additional leaves inserted for notes.
Altogether the book is a very valuable one, and can be especially recom-
mended to those who wish to begin the study of, or review the sub-
ject. D. M. c.

*By Elbert W. Rockwood, M. D., Ph. D., Professor of Chemistry
and Toxicology and Head of the Department of Chemistry in the
University of Iowa, et cetera. Second edition, revised and enlarged.
With one colored plate and three plates of microscopic preparations.
Large i2mo, 229 pages, extra cloth. Price, $1.00, net. F. A. Davis
Company, Publishers, 1914 Cherry street, Philadelphia, Pennsylvania.

PROGRESSIVE MEDICINE.

Progressive Medicine for December is full of its usual amount of
the world's best medical literature. We have praised the merits of
this publication so many times that it seems unnecessary to say more.
It is one of our most welcome visitors. It is impossible to see how it
could be improved. d. m. c.

*A Quarterly Digest of Advances, Discoveries, and Improvements
in the Medical and Surgical Sciences. Edited by Hobart Amory Hare,
M. D., Professor of Materia Medica and Therapeutics in the Jefferson
Medical College of Philadelphia. Lea Brothers & Company, Pub-
lishers, Philadelphia and New York.

A PROFESSIONAL MEDICAL JOURNAL.

VOLUME XXVIII. MAY, 1906. NUMBER V.

ORIGINAL ARTICLES.

MEMOIRS.

MODERN SKIAGRAPHIC TECHNIQUE.*

By VERNON J. WILLEY, A. M., Ann Arbor, Michigan.

DIRSCTOR OF THB UNIVBRSITT HOSPITAL ROSNTGBN LABORATORY.

It is undoubtedly true that the technique employed in making
Roentgen radiographs is, with many who make use of the Roentgen
rays in diagnosis, largely the result of habit and convenience. It is
with most of us, largely a personal problem. It is also true that radiog-
raphy is largely an art, and partakes but little of systematic scientific
application. Yet there are certain fundamental principles, recognized
by many, which are preparing the way for a logically developed system.

What is meant by a good radiograph? What should it show?
How shall we judge whether or not it is technically correct? First of
all it is well to be clear on one point : a radiograph is not a photograph.
It does not represent by its shades and shadows, the real object. It
is a record of the different densities encountered by the Roentgen rays
in their passage through a body made up of materials presenting differ-
ent degrees of obstruction to the passage of the rays. A photograph
is a record of impressions made by rays of light of various degrees of
intensity, reflected from the object to the sensitive plate. There may
be no suggestion of the density of the object photographed. The pho-
tograph represents the real object, and is easy of recognition. The
radiograph is a record of the densities of the different parts or organs
through which the rays pass to reach the sensitive plate, and may or
may not be easy of recognition; in not a few instances it requires a
radiographically trained eye for its correct interpretation. A good
radiograph is one which, first of all, renders a truthful record of these
densities, and is simple and easy of interpretation. Negatives must

♦Read at the Ann Arbor meeting of the First Councilor District Medical
Society, December 22, 1905.

194 ORIGINAL ARTICLES.

be produced showing the greatest possible contrast between tissues of
different density. The differentiation must be sharp and clean cut, the
negative clear, clean, and free from iog or haziness. The simplest
method of judging of the value of the radiograph as to whether it shows
the presence or absence of pathological conditions, is, of course, com-
parison with a normal radiograph. The anatomical structures which
show in the normal radiograph should be carefully studied and com-
pared with the corresponding structures of the radiograph in which
pathological structures may be revealed. Theoretically one should be
able to show by a radiograph any pathological condition involving a
marked change in density of the involved tissues. Practically we are
able to realize this to a very satisfactory degree, but it is useless to
place much reliance upon a skiagraph which has not truthfully recorded
normal structures which differ more in density than the change from
normal to pathological.

The production of a radiograph fulfilling the necessary conditions
depends upon —

First, properly selected electrical apparatus kept in perfect working
order.

Second, properly selected and properly excited vacuum tubes.

Third, suitable accessories for diaphragming the rays, and for
immobilizing the part radiographed, and

Fourth, reliable sensitive plates or films, followed Ky correct and
special photographic technique.

The electrical apparatus, static machine, induction coil, or high
tension transformer should be one with which the operator is thor-
oughly familiar. If he expects to progress further than the elements
of the subject, embraced in the radiography of extremeties, he will
require an induction coil capable of delivering at least a nine-inch solid
flame, and preferably one delivering more than a fourteen-inch flame.
The apparatus must be so adjusted, and supplied with controlling
rheostat and variable inductance, as to respond at once to his varied
requirements. If he is to attempt rapid w^ork, the primary circuit must
be broken by an electrolytic interrupter preferably of the Wehnelt type.
This invention of Wehnelt has done more than any one thing to make
possible the extensive use of Roentgen rays in diagnosis. The Wehnelt
interrupter is simple of construction, works equally well on alternating
and direct currents, and the operator who makes his own and keeps
it in repair has mastered a large percentage of the instrumental troubles
which are likely to confront him.

The fundamental requisite of the Roentgen tube is that its rays
must penetrate the tissues to be radiographed. The thicker the tissues
or the greater the density the greater must be the penetration. The
proper working of the tube is exhibited by the hemisphere of the tube
in front of, or anterior to the face of the anode, fluorescing brilliantly,
clearly, and steadily. The hemisphere of the tube back of the anode
should be quite dark, without fluorescence, and without irregular fluor-

MODERN SKIAGRAPHIC TECHNIQUE. 195

escent rings. This latter condition is important, even though at times
difficult of accomplishment.

The penetration of the tube is a perfectly measurable quantity, and
its actual measurement is an important advance in bringing about
improvement in and uniformity of methods.

A simple form of penetrometer may be made by a combination of
the Renoist i^enetrometer and the aluminum window penetrometer.
Cylinders of aluminum, of two, four, et cetera, to sixteen millimeters in
thickness, and about eight millimeters in diameter, are cut from a rod
of aluminum, and the eight cylinders set in apertures in lead, the first
four in lead one-half millimeter thick, and the remaining four, ten to
sixteen millimeters thick, set in apertures of a strip of lead one milli-
meter thick. The device is then glued to a thin board, and placed in
front of a small fluoroscope. Tubes whose rays penetrate freely the
first four or five aluminum cylinders, and the one-half millimeter lead
strip not at all, are "soft" tubes, or "low tension" tubes, although the
latter term is a misnomer. Tubes whose rays penetrate all the cylinders
and the one-half millimeter lead strip to some extent, are ''hard" tubes,
or "high tension" tubes. The terms hard and soft are purely relative,
having to do only with the penetration of the rays.

The Walter penetrometer is the international standard. Soft tubes
penetrate four or less platinum windows, while hard tubes penetrate
from five to seven windows. Tubes are now designated as Walter
4. 5. 6 or 7. according to their penetration.

Besides being of correct penetrating power the tube must be capable
of enduring a heavy current (amperage) for the required time of
exposure, that is one-half second to six or eight minutes, without over-
heating, lowering of vacuum and lessening in penetration. It should
be one which emits a large percentage of direct rays, supposedly from
the focal point on the anode, and a small percentage of indirect rays,
or rays from the walls of the tube, or at least not from the focal point
on the anode. If a hard tube be used, it is preferable to use one which
has been aged or seasoned to the degree where it will emit rays of a
nearly homogeneous character, rather than a mixture of rays varying
from those of extreme softness to those of extreme hardness. The
tube should be one having a high efficiency as a transformer of elec-
trical energy into Roentgen rays.

At present there is no simple and satisfactory method of measuring
directly the volume of rays given off by a Roentgen tube. The nearest
approach to it is the measurement of a function w^hich is proportional
to it. namely, the current exciting the tube. A milliamperemeter con-
structed to be used in series with the tube indicates, for a given tube
excited by the same apparatus, a current strength proportional to the
radiant output of the tube. Or more strictly speaking, the volume
of rays is proportional to the square of the current strength, provided
the resistance of the tube and the penetration remains constant. This
is very nearly realized in practice, radiographically, for, in exposing a

196 ORIGINAL ARTICLES.

Structure for radiographic purposes, if two milliamperes through the
tube requires an exposure of sixteen seconds, four milliamperes requires
not eight seconds, but only about four, and a radiograph may be made
of the part exposed in one and one-half to two seconds if we can excite
it by six milliamperes. It is possible to secure a good radic^raph of
a one hundred fifty pound man in one second, by using a Walter 6
tube, excited by six milliamperes, from an induction coil actuated by an
electrolytic interrupter.

With reference to the penetration of tubes employed in radiography,
Roentgenologists are divided more or less sharply, into two schools,
advocates of soft tube technique, with attendant long exposures, employ-
ing Walter 3 to 5 tubes, and users of hard tubes, Walter 5 to 7, requiring
exposures of one-half second to ten seconds, for radiographing any
part of the body, while the Walter 3, 4, or 5 tube requires from twenty
seconds to six minutes exposure to do the same work. So far as I
know, there are no radic^raphers who are equally skilled in the use of
both hard and soft tubes.

At first thought it might seem that the advantages are all with the
use of the Walter 5, 6, and 7 tubes. This, however, is not true, as soft
tubes, Walter 5 or less, possess the undeniable advantage of giving
greater detail and contrast in soft parts, especially radiography of abdo-
men and chest, than the average hard tube. In other words, we are
able, by using the soft tube, to record upon the plate more marked
differentiation between tissues differing but slightly in density. In
addition the likelihood of overexposing the plate is very much less than
when using the hard tube. On the other hand there is the greatest
danger of "burning" — it is the rays of slight penetration which produce
changes in the integument.

The difficulty of immobilizing the patient during the long exposure,
the absolute impossibility of radiographing lungs and abdomen during
suspended respiration, and the numerous failures in attempted radio-
graphy of small children who cannot be kept from moving during the
exposure, are drawbacks which have from time to time annoyed and
discouraged the user oi the soft tube. The greatest trouble of all,
however, is the rapid heating of the soft tube under heavy current
excitation, its quickly lowering vacuum following this, and the resulting
lessening of the penetration rendering the tube for the time absolutely
worthless for radiographic purposes.

With the use of the hard tube there is extreme improbability of
producing a dermatitis, even if a dozen radiographs be taken of the
same patient, the same day. It is also possible to secure immobility
of all parts of the body. One can radiograph either chest or abdomen
during suspended respiration, and avoid all blurring of shadow-detail
due to respiratory movements. With a properly seasoned old Roentgen
tube we may pass a heavy current through it for a dozen consecutive
radiographs without materially interfering with its penetration. Such
a tube also possesses a higher efficiency as a transformer of electrical

MODERN SKIAGRAPHIC TECHNIQUE. 197

energy into Roentgen rays. There are some important changes taking
place during the life of a tube, which all experienced radiographers have
noted. The new tube is naturally soft. It produces really good radio-
graphs only when in this condition. Its vacuum is very unstable. It
will heat and run down during exposure, and rise a little higher in
vacuum on cooling. After a time it reaches a degree of hardness
where its rays freely penetrate the bones. It has reached a penetration
of Walter 6 or 7, but it possesses poor definition; that is, the output
of direct rays may be as low as twenty per cent of the energy absorbed,
while the indirect rays may be as great as forty to sixty per cent, the
balance of the energy being transformed into heat. Upon lov^ering
the vacuum successively, it will naturally run longer, without excessive
heating, and not rise as rapidly upon cooling. It is approaching a stage
where its vacuum is more nearly stable. In the course of a year, if the
tube be used for a short time daily, it has undergone remarkable
changes. The glass of the anterior hemisphere becomes darkened.
The glass annealed, the vacuum more constant, it will stand a heavy
current without heating, and instead of fluorescing a greenish-yellow
or an olive green, it will fluoresce a sunflower-yellow, a yellow almost
as pure as the sodium light. Its penetration is about Walter 6. It
gives beautiful definition; the medullary canal of the ulna is clearly
defined by the fluoroscope. It has become a seasoned tube. Its output
of direct rays may rise as high as seventy per cent of the output of
radiant energy, and the rays seem to be much more nearly homo-
geneous in quality than those from a Walter 6 new tube. Such a tube
is worth many times the value of a new tube for radiographic purposes.
It is better to save a well seasoned old tube for the more difficult work,
such as radiography of skull, chest, renal and biliary calculi.

The use of the diaphragm for cutting off the indirect rays is of the
greatest service, particularly when using a comparatively new hard
tube. A scientifically constructed diaphragm, with its accompanying
compression cylinder or compression ring is a necessary accessory to
every fully-equipped radiographic armamentarium.

In the construction of these compression diaphragh cylinders some
deplorable mistakes have been made which appear to be due to a lack
of knowledge of the fundamental principles of radiant energy. When
Roentgen rays or any other form of radiant energy pass from one
medium to another of different density, the particles of the second
medium act as secondary centres for the production of secondary radia-
tions, according to the principle of Huygens. Hence if we would
avoid the secondary rays from the inside of the cylinder, we must
make our diaphragm at the top of the cylinder the truncated portion of
a cone whose apex is the focal point on the anode, and whose base is
coincident with the periphery of the bottom of the cylinder. We are
indebted to Albers Shonburg for the compression diaphragm cylinder
and to Dessauer for first calling attention to the correct principles of
construction of ^ch apparatus.

198

ORIGINAL ARTICLtrS.

It is perfectly possible to make a radiograph by means of these
secondary .i--rays generated from the inside of the cylinder of improper
construction. The direct rays may be intercepted by a thick lead disc,
ami the secondary .t--rays, s (Figure I), allowed to pass through the
structure to be radiographed. On the other hand their production may
be eliminated by the proper diaphragm, while at the same time mini-
mizing the transmission of indirect radiations from the tube. The
accompanying diagram (Figure I) illustrates, in the left hand half of the
figure, a cylinder of improper construction, with its indirect and sec-
ondary rays, while the right half shows how these may be eliminated
by the diaphragm of correct aperture. A diaphragm apparatus of nearly
universal application may be constructed by covering a suitable-sized

FiGURK I. — (d) Apex of cone of direct rays, (i) Indirect rays from walls of tube, (s) Sec"^
ondary rays from cylinder walls.

board or fiber support with a layer of a mixture of putty and mercurous
oxide on the side next the tube. A convenient aperture, of from five
to eight centimeters, is left in the center. This diaphragm, being a non-
conductor, nonmagnetic, and noninductive, may be placed in direct
contact with the tube. Suitable lead diaphragms may be employed for
further limiting the field covered by the rays, and two or more rings
may be detached to the under side of the diaphragm for purposes of
compression or immobilization. The diagram (Figure II) will make
clear its construction.

The compression rings of seven and one-half and ten inches in
diameter, in addition to a five and one-half inch cylinder, will fulfill
about all of the requirements demanded of such apparatus by the radiog-
rapher.

Lastly, I wish to mention briefly the photographic technique. The

MODERN SKIAGRAPllIC TECHNIQUE.

109

radiograph is a special negative. It should possess strong and emphatic
contrasts. Two of the most important factors in the production of the
best grade of radiographs are the correct exposure, and the correct
developmental technique. The physician who exposes his plates, and
then passes them on to a portrait or landscape photographer for devel-
opment, will not obtain the highest grade of work, until both learn
by experience the important difference between a landscape or portrait
negative, and a radiographic negative. A different developing formula
and a different duration of development are essential. Especially is
this true if the hard tube technique be employed.

In conclusion, I may say that while a great deal depends upon the
apparatus and its correct management, there is also the personal factor

Figure II. — (a) Layer of putty and mercurous oxide. (b) Wood or fiber support,
(c) Metal diaphragm, (d) Cone of direct rays.

of the radiographer. If he would succeed he must train his judgment
by keeping a careful record of all exposures, and making careful
measurements of all the factors which he employs, which are capable
of measurement. It is only by persistent systematic training that he
can ever hope to be able either to duplicate his best results or to place
his work on a scientific basis.

The use of the Roentgen rays in diagnosis has made remarkable
strides since the presentation of Roentgen's paper upon its discovery,
ten years ago this month. If the next five years are as fruitful in

200 ORIGINAL ARTICLES.

progress as the last five, even the skeptics will be compelled to admit
that this new diagnostic and therapeutic agent is the most useful, if
not the most interesting, contribution that the science of Physics has
ever made to the science of Medicine.

A SURGICAL PILGRIMAGE TO ARKANSAS.
By HAL C. WYMAN. M. S., M. D.. Detroit, Michigan.

PROPBSSOIl or SURGBKY IN THB MICHIGAN COLLBGB OP MBDICINB AND SURGBRY.

Arkansas was settled originally by people from Tennessee, and
consequently the Arkansans maintain the customs and trend of thought
common to the Tennesseeans. In the early days of that state, there
was a law to the effect that if a negro went about the country prac-
ticing medicine or healing the sick, he was punished by a drubbing not
to exceed twenty-five lashes, while his master, if he were cognizant of
the fact, was liable to a fine. The people of Tennessee would not allow
any "free" colored person to remain in their state more than twenty
days, and slaves were never permitted to assemble in unusual numbers,
without the expressed consent of their owners. In Arkansas now
there is a State Medical Society composed entirely of colored physi-
cians. I met the president. Doctor Claude M. Wade, during a recent
sojourn in Hot Springs. I found him a regular graduate in medicine,
practicing his art in accordance with the laws of the state. He is at
the head of the Saint Pythias Sanitarium in that city, an institution
with twenty beds, which takes patients of any color. The medical law
of Arkansas recognizes all the "pathies." If a man would practice
regular medicine, be he white or colored, he must appear before a
board of regular physicians, exhibit his diploma, and pass a satisfactory
examination. If he is an eclectic, as many of them are, he is required
to appear before a board of that persuasion, exhibit his diploma, and
give written evidence of qualification in order to gain the right to
practice.

Hot Springs, the mecca of many medical pilgrims like myself, is
located in Garland county, and after having visited all its sanitariums,
including the splendid institution of Doctors Holland and Laws, I
visited the County institution about four miles distant from the city,
over West Mountain. Judge of my surprise, after finding the color
Hne in the city so distinctly drawn as to require two separate medical
societies, at finding the County Poor House containing inmates, both
white and colored, without separate buildings. In one little building,
called the "jail," or *'crazy house," I found two helpless melancholic
female patients in the midst of the most wretched filth and fetor, in
cells adjacent to three men afflicted with acute mania, one of whom
was colored. One of these poor women had stripped herself of cloth-
ing, torn her bedding to bits, and during the recent cold nights had
her feet frozen, so that great sloughs of skin and fascia were now
adding to her discomforts. The crazy negro wanted to kill somebody

A SURGICAL PILGRIMAGE TO ARKANSAS. 201

all the while. One of the men had epileptic seizures two or three times
a day. The other woman shrieked and moaned almost incessantly,
begging to be taken to her home. A' physician comes out from Hot
Springs at intervals to visit these unfortunate people, instruct the man-
I ager in the art of cleaning the cells, and making the occupants comfort-

i able. Other of the inmates, irrespective of color, were wandering

^ about the little frame building in all stages of mental debility, from

low grade idiocy to the lighter forms of senile and moral imbecility.
I had a talk with Doctor Joseph W. Shaw, at his office in Buckville,
about twenty-five miles from Hot Springs, about the people I saw in
the County Poor House, and he said they ought to be sent to the
asylum at Little Rock. He had served several terms as a member of
the legislature from Montgomery county, and his son. Doctor Argus
D. Shaw, of Hot Springs, was county physician at the Poor House.
Doctor Shaw is a fair type of the better qualified rural practitioners of
Arkansas. He has been in practice since the close of the Civil War
and is thoroughly familiar with the law governing the care and med-
ical treatment of pauper and insane persons. He told me that it was
the custom to let the paupers out to the highest bidder, that is, a man
who would agree to keep the pauper in his own home for the lowest
figure per annum would get the patients ; and with the insane, unless
the malady was pronounced, the same rule obtained. But when the
i case was at all severe, the person was tfiken before the county judge,

and examined, the testimony of the physician in attendance being taken
and the patient sent to the asylum at Little Rock. I could not learn
of any very careful discriminating examinations to determine the likeli-
hood of this or that operation or treatment being useful to the patient.
The county judge does the examining and the physician merely deter-
mines the question of insanity, basing his conclusions on the disposition
of the patient, without regard for the pathology, surgery or therapeutics
in the case. Doctor Shaw has another son practicing with him, and
together they do most of the practice within a radius of twelve or
fifteen miles, riding the rough mountain trails, and fording the moun-
tain torrents on horseback. They have some malarial fever and Doctor
Shaw, elder, is not a believer in all phases of the mosquito theory.
He doubts whether the mosquito is the only vehicle for the conveyance
of the Plasmodium malariae. There are occasional cases of appendicitis
occurring in the mountain regions remote from the city hospitals and
surgical sanitariums of Hot Springs and other cities, wherein the rural
practitioner does his own operating, and in more than many instances
I found physicians splendidly equipped with a knowledge of the serious
' phases of abdominal surgery. The city physicians of Arkansas are

reluctant to go into the country, for the reason that the people in the
fastnesses of the Ozarks, though happy, are often poos, consequently
I the doctor on this or that creek, or in this or that hollow, as the country

is spoken of, must do his serious surgery himself. At the little town
of Harrison in the midst of a most rugged country teaming with

202 ORIGINAL ARTICLES.

I^ople living in the easy way of the Arkansan, there is a doctor whose
fame keeps him busy and brings him all sorts of surgical cases within
a radius of from fifty to sixty miles. His results in hernia, appendi-
citis, and ovariotomy are just as good as those obtained by any man.
The pure air, the fine water of the mountain districts, as well as the
skill of the operator are strong factors in the recovery of patients.

The medical visitor at Hot Springs is not surprised at the character
of ills observed on the much frequented streets. One of the grandest
clinics in the world may be observed passing in an almost endless pro-
cession through the principal streets and about the springs. Just why
the hot water emanating from the earth at this place should possess
such great value in the cure of many chronic ills is difficult to say, but
certainly it has the power of attenuating and eliminating almost any
poison contained in the system of those who drink enough of it. It
increases voluminously the excretory functions of the skin, kidneys,
and bowels. The Government controls the sources of the water, there
being a reservation maintained by the United States. Entrance to this
reserve is indicated by two huge gate-posts, surmounted by bronze
eagles, and illuminated with the name of "Hoke Smith,'* who happened
to be Secretary of the Interior when certain improvements on the Gov-
ernment Reserve were made. I cannot but consider the disfigurement
of these two splendid gate-posts with the name of Hoke Smith cut upon
them a matter of very bad taste, but since this officer was one who
cleaned out the **old mud hole" — the ''^old ral hole," as it was called by
countless thousands, who bathed in it and were cured of their specific
ailments — and substituted for it the present free bath-house, where any-
one who registers his name, may receive a bath in a clean porcelain
tub and cement pool, free of charge, I do not see why the medical visitor
at Hot Springs may not pass judgment on matter of taste and public
policy. It is not considered in good form for officers of the United
States government to have their names cut in the solid stone to com-
memorate any of their acts performed as the servants of the people.
The profession in Hot Springs is in a state of turmoil, into which they
have dragged the courts, over the matter of drumming for patients.
A X'isitors' Protective League exists among the physicians, and its
function is to ascertain and endeavor to stop the practice. The United
States Government has jurisdiction over the water coming out of the
Government mountain on the reservation and will allow only those
whom it examines and registers as competent, qualified physicians to
prescribe the water for their patients. There are a great many physi-
cians in Hot Springs who are not permitted to use the water of these
springs in their practice.

Surgery in Hot Springs is not practiced very extensively, as com-
paratively few of the horde of invalids coming here present operable
cases. There are a number of sanitariums with neatly equipped oper-
ating rooms, where all sorts of operations may be performed. There
are numbers of men skilled in the surgical arts, who are ready at any

A SURGICAL PILGRIMAGE TO ARKANSAS. 203

hour of the day or night to perform any operation needful for the relief
of human suffering, and there are plenty of trained nurses, too, who
like surgical cases, but relatively few operations are perfonned. Hot
Springs is not a surgical center, it is a place where drugs are tested
to their full value and where the healing powers of the hot waters of
the earth exert their greatest efficiency. A curious custom prevails
among the physicians in regard to charges. The consultation fee, or
first visit of a patient to a doctor, is five dollars. He is then informed
that the subsequent charges will be twenty-five dollars per month,
invariably in advance, and no matter what the disease, the patient
may come to the doctor's office as often as he thinks the condition
demands attention. I was told that this rule in regard to charges and
custom in regard to visits was established very early in the history of
the springs, that it works admirably, and that all the patients sitting
in the doctors' waiting-rooms represent pay patients, on the twenty-
five-dollars-a-month plan. The doctors are located, mostly, on one
street, facing the Government Reservation. Generally their offices are
over the stores, and the patient must climb a long flight of stairs. The
doctor, in prescribing baths, writes his instructions, which are carried
out to the letter in the bath-houses on the reservation using the hot
waters. I saw some very interesting cases of necrosis of the bones of
the face, nasal bones, grouped about the hot springs inhaling warm
vapor which rises from the waters in the early morning. Many of
these poor people were in need of surgery, to cut away the diseased
bone.

The country around about Hot Springs is mountainous, the town
being situated in the foot-hills of the Ozarks. The drainage of the
country is through the Ouchita river, a beautiful stream heading up
near Indian Territory and Arkansas. The hills are covered with
splendid forests of pine, oak, ash, gum, and hickory. In many of the
hills gold has been found. In almost any direction you may travel on
horseback you will find extinct mining camps, where dilapidated build-
ings and rusted-out machinery are to be seen. The region for twenty-
five miles about Hot Springs is quite thickly populated, notwithstanding
the forests, and nearly every section of land has one or two families
living upon, it in neat little log cabins with plenty of children whom I
found invariably healthy and happy, subsisting largely on a diet of
corn meal which is grown in a patch of rarely more than four or five
acres (usually the only cultivated ground about the homestead), and
the delicious meat of the long-nosed, half-wild, razor-back pig, which
thrives the year around on roots and nuts. Once iyi awhile a church
or a school-house is found, and on the streams occasionally a mill with
the old French burrs for grinding corn, which preceded the introduction
of the modern roller process of milling grain. The simple diet of the
native Arkansans who settled this country in the thirties largely, main-
tains a sturdy class of citizens. I would not have you think that hog
and hominy is the sole diet of these people. The mills just mentioned

204 ORIGINAL ARTICLES.

make splendid meal of the pure hard corn, which thrives everywhere
in the country around Hot Springs. This meal contains all the nutri-
tive elements of the grain, and is quite different from the product of our
northern mills. The people have cattle and use milk and butter to a
moderate extent. They are not, however, well posted in the science of
dairying, and I fear the rugged little cattle are not profitable producers
of fat. They are so numerous in the country I traveled over that they
have devoured all the canebrake which used to fill the valleys and low
places along the mountain streams. Their hides are a source of income
to the mountain farmer, or cracker, as he is sometimes called. Inquiry
revealed an occasional case of anthrax and progressive purulent infec-
tion of the hands of persons who had been handling hides of cattle
found dead in the woods. I could not learn that deaths were due to
tuberculosis among the cattle, but believe that they were the result
of insufficient food during the winter period, a little shorter though
much less severe, than that of Michigan. The people are beginning
to learn the value of poultry as a food, and as a means of increasing
the family revenue. I found fine chickens about every homestead, and
fresh eggs and fresh fowl supplement the pork and corn meal diet I
have been writing about. In the little field about the house, are com- *
monly grown a few potatoes of the Irish variety, and a larger quantity
of sweet potatoes, which are secured for use through the winter season.
Cabbage, turnips, cauliflower, tomatoes and all sorts of wild fruits and
berries are valuable adjuvants to the foods I have just mentioned.
The total cost of living on a good wholesome diet in the country round
about Hot Springs is surely not very high. Corn is worth fifty-five
cents a bushel shelled, a bushel loses one-eighth in the process of grind-
ing, and will feed, when made into meal, a family of five persons three
weeks. That is only two and one-half cents per day. The pork, dressed,
is worth six dollars a hundred, and a family of five persons will eat
three hundred sixty-five pounds a year. That is about six cents a day,
making the total cost of living for a family of five persons about eight
cents a day. That this diet, inexpensive as it is, is sufficient for good
sound health and mental vigor is amply attested by the freedom of the
people from tuberculous infections, chronic anemia, or neuritis.

Not a small part of the curative value of a sojourn at Hot Springs
is due to frequent excursions, either on foot or on horseback, into the
mountainous country round about the town. The better qualified phy-
sicians nowadays advise these excursions as a part of routine treatment
accompanying the baths, and they are of fully as much value as the
massage and inunctions liberally practiced. I could not learn that
anyone was doing anything in a surgical way for the cure of nerve
syphilis. Tlie well-known fact that a surgical operation upon the cra-
nium— opening the bony vault of the skull with the trephan — often
determines the action of the iodide of potash in these cases of cerebral
disease commonly attributed to venereal infections, seems to have passed
unnoticed.

A SURGICAL PILGRIMAGE TO ARKANSAS. 206

Eureka Springs, in the northwest corner of Arkansas, has a wide
reputation on account of the purity of its waters. They are quite free
from solids, and are cold, carrying more oxygen than the waters of
Hot Springs. The purity of its air, and the very rugged, broken char-
acter of the country in which they are located, commands attention.
There are more than forty springs inside the town, and one can get his
fill of the solvent diluent at almost every corner. In the treatment of
rheumatism and nephritis, these waters are quite unsurpassed. The
man with the torpid, sluggish liver, renal insufficiency, and a feeble
heart, will, if he drinks these waters and climbs these hills under the
direction of a skilled physician, commonly find the obstruction to his
circulation soon disappear, his respiration grows less frequent, his
sleep become less fitful and restless, and his general condition vastly
improved ; but even here I found, in conversation with physicians, that
a high degree of skill is necessary to achieve results in the treatment of
rheumatism, nephritis, eczema, or the distressing pruritus, often found as
symptoms of impaired nutrition of the central nervous system. Nor is
Eureka Springs a surgical town ; there is not a hospital or sanitarium
in the town. All the surgery is the homemade sort, and is per-
formed wherever the need of it is manifest. People with tumors do
not come here, although I believe not a few cases might be found in
which the solvent action of the water in cases of chronic empyema of
the gall-bladder, and the agglutination of the ducts might be supple-
mented by a surgical operation for drainage of the gall-bladder. Bath-
houses are plentiful, fine hotels are numerous, good food is abundant,
and pure air is universal at Eureka Springs. In a talk with Doctor
Russell G. Floyd, who has a wide reputation in the treatment of
nephritis, I was pleased to learn that he advised stripping the kidney
in many of the cases of water-log nephritis, that he gave the patient
plenty of the pure waters of the springs to drink, that he prescribed
digitalis, and that he subjected them to vapor baths, massage, and cold
douches with the most gratifying results. Doctor Floyd invariably
treats the eczemas and pruritics with copious dilutions of the fluids of
the body, by having the patient drink daily one or two gallons of the
pure spring water, and bathe in warm spring water, whitened with
bags containing four or five pounds of bran to each twenty gallons of
water. Exercise on the hills, climbing the mountain paths, or follow-
ing the bridk trails on horseback are valuable accessories of his treat-
ment. The country here is free from mosquitoes, and no stagnant
water is found anywhere. The whole region around about is underlaid
with caverns, and into these the waters filter through the flinty soil,
to appear finally in the beautiful strong flowing White river which
rises in and drains this region of the Ozarks.

I learned of a fever not altogether rare, which the doctors told me
is neither typhoid nor malaria, but may be appendicial. It seizes the
patient in the form of a high temperature, lasts from three to four
weeks, and commonly ends in recovery if treated with hot sponge

206 ORIGINAL ARTICLES.

bathing. It lacks the stepladder rise of temperature in typhoid, as well
as the intermission and the remission of the malarial fevers. Xor is it
in the least influenced by quinine. It occurs at almost any season of
the year and is found in any part of the Ozark mountains. The local
doctors call it mountain fever, slow fever. It is never epidemic, nor
is it moscjuito-born, for it prevails in localities where mosquitos are
never seen. There is tenderness in the reg^ion of the appendix in most
of the cases, quite suggestive of appendicitis. May it not be a type
of ulceration of the appendix mucosa, allied to the ulceration of Pyer*s
patches, a characteristic of typhoid? Near the I>asin Park Hotel is a
large spring and a little park, where, during the Ix-ttcr ])art of the two
himdred odd bright days of the year, may be seen numbers of people,
who come here to drink the water, and increase their stock of health.
The pallid face, the puffy eyelids, and the hurried respiration of the
nephritic patient is frequently seen among them, and in almost every
instance these people are improved, not a few being absolutely cured
by the waters of the springs and surgical stripping of the kidney.

Fort Smith. Arkansas, is a city of twenty odd thousand people on
the border of Indian Territory. It is in Sebastian county on the
Arkansas river at the head of steamboat navigation. The Sebastian
County Medical Society has a membership of forty-two, but there are
about one hundred seventy-five doctors in the city, and they are all
either irregulars, eclectics, or homeopaths. The mass of practice is
in the hands of the irregulars. The profession lives in reasonable
harmony. There are several very good surgeons, who operate at the
City Hospital and at the Saint Vincent, a Catholic hospital. There is,
however, no great amount of surgery done. Some of the operators
having met with disaster in their abdominal work have caused the
people generally to be averse to surgical procedures. They prefer to
trust to powdered roots, fluid extracts, and divers teas for the relief
of their ills. Some of the doctors, however, have large practice, visit
a great many patients, and put up or dispense bushels of medicine.
Malarial fevers are not uncommon. Quinine and other alkaloids of
Peruvian bark are in constant use. Calomel and epsom salt seem to
be effective in most of the abdominal cases. The positive obstructions
are either operated upon, with more or less reluctance, or go surely to
the bad. I could not learn that there was much surgical enthusiasm
in Fort Smith. It is a fine growing city, full of splendid homes, in
the midst of a fertile country, maintains two ambulances owned by
undertakers, who are a thrifty class. There is an. opportunity in Fort
Smith for an apostle of surgery, but he must cure the people whom he
operates upon.

My medical jaunt to Arkansas would not be complete without some
account of Little Rock, the capital of the state, wdiere are located the
niedical department of the Arkansas Industrial University, Saint Vin-
cent's Hospital, and the Logan H. Root Hospital. Mr. Root endowed
the hospital with $too.ooo, but only $10,000 of that sum was found

A SURGICAL PILGRIMAGE TO ARKANSAS. 207

available by his executors for the uses of the institution. The clinics
of the medical college are in part held there, and as good courses in
clinical medicine and surgery are given in Little Rock as in any city
of its size in the United States. The Medical College was founded
about twenty years ago and it numbers among its alumni many of the
ablest physicians of the state. Little Rock has about fifty thousand
people and is growing. It has Saint Vincent's Hospital, a church
institution; a Railroad Hospital under the care of Doctor Joseph
P. Runyon, who is generally recognized as one of the leading surgeons
of the city ; and a City Hospital, in charge of Doctor Watkins, the city
physician. At the County Hospital and Poor House, a short distance
from the city, senior medical students act as internes, and get a part of
their course in clinical obstetrics. Little Rock has a School for the
Blind — both white and colored, a School for the Deaf — both white and
colored, the State Penitentiary, and the Asylum for the Insane, which
contains more than one thousand patients. All of these institutions
furnish more or less medical and surgical work, which is available for
the instruction of industrious and enterprising medical men. In the
Asylum for the Insane the custodial features of the work is paramount,
but not a little attention, probably fully as much as in asylums generally,
is given to the internal medication of the patients. Gastrointestinal
work is done tentatively, but every patient is given a careful physical
examination, which supplements the perfunctory examination carried
out under the direction of the county judge. There is, however, no
reason to contrast the medical and surgical care of the insane of Arkan-
sas, outside of the Poor House in Garland county, with the care that
is given those people in other states. At Fort Smith they have a fine
Poor House under the care of able physicians, and the most conscien-
tious and discriminating treatment is given to the patients. The same
may be said of that institution at Little Rock and of the asylums gen-
erally. The blot on the escutcheon of Arkansas in Garland county,
near Little Rock, a prominent physician in Little Rock told me, is the
fact that Hot Springs is the mecca for countless thousands of people,
mostly poor, who suflfer from constitutional diseases and pour into Hot
Springs in great numbers. If the municipality built a city hospital
they would swamp it. If they kept a decent Poor House they would
swamp it. ]\Iost of the inmates of the County Poor House were from
other counties and states, who had come to Hot Springs with the hope
that the hot waters would heal them, and had no means to get away.
He further said that it was the policy of the municipality of Hot
Springs to discourage the coming of poor people to that place, by with-
holding all the usual eleemosynary institutions from their use. Even
the jail, I found overcrowded and a relic of antiquity. It was built
in the early days of the county and ought to discourage every evil-
minded person w'ho looks at it, much less stays in it.

The expectation of finding any considerable amount of up-to-date
surgery and surgical institutions in Arkansas were not fruitless; and

208 ORIGINAL ARTICLES.

there is good reason to believe that the small band of vigorous, aggress-
ive, well-equipped practitioners of the chirurgic art will meet with
better reward in the near future. The wealth of Arkansas forests, her
mines of coal and metal, her cattle, sheep and hogs, her grain and cotton
cannot help but bring a population which will want more and better
schools, ask more and better care of their minds and bodies, and con-
sequently give employment liberal and ample to those who stand today
. for the advancement of medicine along the most progressive lines.

THE VALUE OF TIME AND NATURAL UTERINE EFFORTS
IN PARTURITION.*

By ALVAH N. COLLINS, M. D, Detroit.

If the signs of the times indicate anything to the more mature
medical student, they indicate a closer study of the natural processes
in the care and cure of those seeking our advice and assistance. This
is true as well of surgery as it is in so-called general medicine and
obstetrics. In general medicine we cannot fail to note a falling off in
complex drugging and active interference. Given a complex prescrip-
tion containing a 4ialf dozen different ingredients, the ultimate action
of which, given separately, we know little enough, when combined, we
know less. We had a specific that was good for this symptom and
that symptom, while at the same time it might be hammering the life
out of some other vital part of our machinery, unnoticed, in our mad
pursuit of the particular symptom. How the multitudinous remedies
have dwindled in this renaissance of more accurate observation. Just
now in all branches of medicine the pendulum of all active interference
without a very plain indication is swinging back toward a reasonable
letting alone of all the natural processes unless we have a plain indi-
cation for interfering, either mechanically or medicinally, with an
organization in which countless generations have developed recuper-
ative and curative properties and which, in many cases, now interfered
with were much better left alone. The man who always has his
monkey-wrench in his automobile will do considarable walking. The
doctor who cannot keep his fingers out of the delicate processes of the
animal machinery will often do irreparable damage to the nicely
adjusted and wonderfully complex machinery of the living organfsm.
Nevertheless, there are times when the monkey-wrench will help the
machine and there are unquestionably times when the careful physician
will assist in benefiting the laboring organism. I simply plead for more
care and judgment when to, and when not to, interfere. If a labor is
going along reasonably well, if there are no apparent reasons why a
natural labor may not be consummated, in the name of all that is
sacred let it alone.

•Read at the Ann Arbor meeting of the First Councilor District Mrdical Soci-
ety, December 22, 1905.

NATURAL EFFORTS IN PARTURITION. 209

The subject of obstetrics is a broad one, and I will confine myself
to one phase — the value of time and natural uterine efforts in parturi-
tion— drawing my conclusion very largely from mistakes that I have
made myself, and from mistakes that I have seen, and known of others
making. In an experience extending over a period of twenty years
it was my misfortune to have a very large obstetric practice. I cannot
compete with some figures I have heard as to number of cases so will
give no figures, but conclusions drawn not so much from books as
from the bedside. We need to have a fairly definite knowledge of
what is the average time necessary for normal labor. We must take into
consideration that this is so modified by individual peculiarifies that
one patient may need hours for certain changes that are necessary for
safe delivery to take place while another will only need minutes. Each
patient has a normal period of time distinctly her own. Yet from the
study of a large number of cases we estimate a fairly definite period
during which the process is completed. This period, as you have all
observed, often varies greatly in the same patient, differing presenta-
tions, differing size of child, differing physical conditions, et cetera,
all modifying the time needed for the most conservative and safe com-
pletion of this truly awful phenomenon, parturition.

Hirst states that the average duration of all labors is from twelve
to fifteen hours: in primaparae from twelve to twenty- four hours; in
multipara from six to twelve hours.

In Spiegelberg's five hundred and six cases, commonly quoted, the
three stages for primiparae are, stage of dilatation, fifteen hours ; expul-
sion, two hours; third stage, one-half hour. Multiparae — dilatation,
eight hours ; expulsion, one hour ; and placental, one-half hour. A proper
conception of -the long time necessary to bring about a condition of the
parts for a safe delivery, a delivery as free from injury to the struc-
ture of the parturient canal and with as little offense to those organs
as is possible, is the sine qua non of obstetrical practice.

My observation and experience at the bedside have shown me con-
clusively that more damage is needlessly done from a failure to remem-
ber that the normal period of the stage of dilatation in primiparae is
fifteen hours and may be thirty-six hours or more and still be normal
for that case, than from any other one cause. I am satisfied that
many a woman in her first labor is unnecessarily injured and made a
semiinvalid, forever after to be a supplicant at the shrine of the gyne-
cologist, from this failure on the part of the attendant to properly
realize the necessity and value of time for the physiological changes to
be brought about for safe delivery. I am not discussing abnormal
conditions. Abnormal conditions may imperatively demand violent
treatment of these organs as a lesser of two evils. Whenever we for-
get the value of time in parturition, and with our anesthesia and our
forceps force these delicate structures to dilate and stretch to their
utmost and beyond before they have been prepared for the ordeal by

210 ORIGINAL ARTICLES

hours of natural effort we are meddling with a process greatly better
let alone.

The process of dilatation of the cervix, the obliteration of the cer-
vical canal, the relaxation of the lower uterine segment or the so-
called ring of Bandl is a slow process. If given time the uterine con-
tractions, pulling by the longitudinal fibers from above against a con-
ical wedge within the uterus, gradually dilate the opening, making
the heretofore contracted canal a cylindrical part of the uterine body,
permitting the escape of its contents without great injury to its own
structure or unnecessary pull upon the ligaments supporting the
uterus. This dilatation can by no mechanical means known, be so
safely accomplished as by the physiological process attending the
phenomena. A certain degree of edematous infiltration of the lower
segment results from the paroxysmal contraction and the relaxation,
which requires time. This infiltration permits relaxation without
laceration.

In the second stage of labor, in preparing the pelvic floor and
vaginal outlet and perineum for the great distention that is to come,
this infiltration is undoubtedly of the greatest value in permitting a
relaxation without rupture. This process of infiltration requires time.
In the second stage, especially in primiparae, without very clear indica-
tion of necessity for hasty delivery, we should permit all the protective
processes of infiltration, paroxysmal distension and recession, and
gradual dilatation ; ample time to prepare for the stretching that must
otherwise result in laceration; which in the majority of cases physio-
logic law exacts. How unwise and how unscientific then does it
become to resort to forceps before we have the best possible obliter-
ation of the cervical canal and lower uterine segment which terminates
the first stage of labor.

To apply the forceps high up before the head has entered the brim
or descended into the excavation, even with a well dilated or dilatable
lower segment, is a dangerous procedure, I quote from the "Ameri-
can Text-Book of Obstetrics": "It should be resorted to only in
exceptional cases. The higher the head the more dangerous the pro-
cedure." How much more dangerous to apply high forceps before we
have a proper dilatation and exert the strength often applied to the pull
upon a lower undilated uterine segment. What are we pulling upon ?
We are dragging with all the force exerted, upon the uterine ligaments,
the round ligaments, lower part of the broad ligaments and the utero-
sacral bands. If the bony structure of the pelvis resists us we then
endanger the anterior supports of the bladder, urethra, and vagina.
If our eflforts are successful in dislodging the head from the rapidly
dilated lower segments, what then occurs if we continue with our
delivery ? ' We bring the head down upon the pelvic floor and peri-
neum to the second stage of labor which requires normally two hours
and may normally require from two to six hours. Do we sit there

NATURAL EFFORTS IN PARTURITION. ^ 211

from two to six hours or permit a proper time for the proper relaxa-
tion of this pelvic floor? We should if we are to properly protect our
patient. As a rule, when the forceps are on, the process is continual
and the delivery completed within an hour at the outside. The result
is unnecessary injury. We have not taken into consideration the
value of time in this process. This picture is not overdrawn. A short
time ago I was called to repair a primiparae where the whole process
of the three stages had been accomplished with the forceps in about
four hours. The result was two tired physicians and a genital tract
that looked as though a stick of dynamite had been inserted therein
and exploded. No sugeon can by any sort of repair ever overcome the
damage done. The only recourse is to make the best, by careful effort,
of what was rendered irreparable. It is because I have witnessed this
sort of work so long that I wish to call attention to the trite subject —
the value of time and natural uterine efforts in parturition. Again, in
induced premature labor, I have seen the process so unduly hurried
that a small child rapidly delivered caused such shock that the mother
never recovered. Do not understand me to be criticizing necessary haste
when haste is plainly the lesser of two evils ; but I wish to emphasize
the dangers of too rapid delivery. I wish to state my conviction that
in many cases of delivery today the forceps are used altogether too
early and too often. We should not permit a woman to die of
exhaustion, but the proportion of women dying of exhaustion and
delayed labor are few compared with those invalided for life and dying
from precipitate artificial delivery.

Is there need to again direct attention to the evil results of hasty
and forced delivery in the normal but slow parturient wcMnan? My
experience answers this question in the aflirmative most emphatically.
Once a pelvic floor is severely torn I very much doubt if any care,
no matter how skillful the surgeon, can restore it to its original tone
and function. We may carefully adjust the torn muscle and tissue
in sight or in reach but we cannot see or reach the upper margin of
the support. Recognizing this impossibility^ of complete restoration
it becomes imperative that we use every means at command to prevent
a condition being brought about which is incapable of repair. In my
judgment the most efficient protection against calamities, farreaching
in their immediate as well as remote effects, is in allowing plenty of
time for the natural protective processes to physiologically prepare this
tissue for its great distention. If given plenty of time a very difficult
delivery, if forced, becomes relatively jeasy and free from danger. In
many cases of prolapsus in later life the so-called rectocele and cysto-
cele are due to too rapid delivery in the second stage of labor. No
matter how carefully we may repair a perineum or how perfect our
union, a vagina once torn from its pelvic attachments is very difficult
if not impossible to repair. This detachment may be and usually is

212 ORIGINAL ARTICLES.

subcutaneous and undetected till the woman has been on her feet
several weeks.

There can be no reasonable doubt but that the early use of the for-
ceps and the semivoluntary excessive bearing down of the patient, or
in other words, too rapid movement in the second stage of labor, is the
prime cause of this tearing away of the pelvic attachments of the
vagina, the results of which are rectocele, cystocele, and later in life
uterine prolapse. If this be true, in most cases we do our most effi-
cient service by retarding rather than hastening the second stage of
labor. With no contraindication I believe this procedure should nearly
always be done by employing anesthesia and exerting manual press-
ure upon the distended perineum. This can usually be accomplished
by giving the parts ample time to relax to their utmost. You are all
familiar with the complete lacerations often found in cases of precipi-
tate labor when there has been no opportunity to protect these tissues
by compelling a slower process. They but teach us what not to do
with our forceps and how to protect these structures when opportunity
is given.

In the delivery of the oncoming shoulder, time again should be
given. No doubt deep pelvic floor injury is often increased if not
caused by a too rapid shoulder delivery. Time is here needed for
rotation and adjustment of the bisacromial diameters to the antero-
posterior diameter of the outlet. With the anterior shoulder behind
the pubic bone, the cervicoacromial diameter permits the posterior
shoulder to emerge first with less strain upon the pelvic floor. When-
ever possible, with no contraindications aside from gently elevating
the head, the posterior shoulder should be allowed to pass over
the perineum with no effort at manual extraction whatever. This
method of shoulder delivery is the natural one and simply requires let-
ting alone largely till the physiologic forces complete their work. If
any traction should be required in the delivery of a large child the pos-
terior foreams should be gently flexed out over the perineum and a
gentle traction upon the posterior shoulder made, allowing the yielding
body to permit the delivery of the anterior shoulder under the pubic
arch. Again, in the third stage or placental delivery the element of
time is too often overlooked, and pushing from above and lugging at
the cord below is resorted to instead of gently kneading the uterus and
permitting a natural and complete delivery. You are all familiar with
the saying that adherent placentae are found mostly in the first few
cases attended. It is surprising how seldom they are found later in
our professional careers. It requires from five to ten minutes for the
relaxed and relatively empty uterus to regain sufficient contractability
to commence efforts of placental expulsion. Its first efforts are usu-
ally futile. More time and more stripping oflF by the retained blood
are required. The only point we need to know is, has the uterus its
tone? This, by manual touch through the abdominal wall, is readily

NATURAL EFFORTS IN PARTURITION. 213

determined. If permitted, within fifteen minutes or a half hour the
process will be completed in a way more satisfactory and safe than man
has devised. Again, the value of time versus meddling !

CONCLUSION.

It requires time to bring about a proper condition of the cervix and
lower segment of the uterus for the safe delivery of the presenting
part. This is a variable time, and when there are no urgent contra-
indications this time should be given — be it three hours or three days.
My experience and observation force me to conclude that this is very
often forgotten at the beside, with lamentabte consequences to our
patients. The forceps are applied altogether too frequently and alto-
gether too early in a great number of cases. When employed they
are not used with sufficient deliberation, and results are brought
about in minutes which, in order to properly protect the tissues, should
take much longer time. The strain upon the tissues is too continuous
to properly protect the child or the maternal tissues. The strain should
be interrupted instead of continuous. The interval of strain should
not exceed one-half minute without a relaxation. More time than is
usually given is imperatively required if we are to relax instead of
tear the tissues. We should not forget that we are pulling upon deli-
cate structures which must oppose our strength with theirs, pound for
pound. We should not forget that before time for relaxation has been
given a force of fifty pounds will do more damage and accomplish less
than a ten-pound pull with proper relaxation. We need to fix in our
mind the time for the various stages of normal labor and conform as
nearly as conditions will permit to these periods, not forgetting that
more time in individual cases may be given when there are no plain
contraindications. Watch the progress of natural labor with more
of a readiness to assist natural processes than with an idea of taking
the job entirely into our own hands. I quote the indications for the
use of forceps from the "American Text-Book of Obstetrics.'*

(i) Indicated in lingering labor when the natural efforts are
unable to effect delivery.

(2) When speedy delivery is imperative in the interest of the
mother; as in hemorrhage, exhaustion, convulsion, advanced cardiac
or pulmonary diseases, et cetera.

(3) When speedy delivery is indicated in the interests of the child,
as in impending death of the mother or threatened asphyxia of the
child.

And again, a quotation from Doctor John W. Clark in his "Resume
of Prolapsus,'' published in the June (1905) number of "Progressive
Medicine," expresses the facts of this subject :

( I ) Never encourage a patient in labor to bear down until nature
excites this inclination.

214 ORIGINAL ARTICLES.

(2) The use by the patient of tractors to increase the voluntary
expulsion effort is questionable.

(3) Never apply forceps without a complete dilatation of the cer-
vix. When a more precipitate delivery is necessary it is best to incise
the cervix.

Never use forceps without a positive indication. Secure the gradual
passage of the head through the vagina and over the perineum.
The prevalent use of artificial force, the habitual use of the forceps
without any prime indication for their use, the rapidity with which
labor is consummated by these artificial means with the train of evils
that follow this departure from natural physiological law is what I
would emphasize.

Because a patient or her friends insist that something be done is no
valid indication for harmful practice. It is our duty to protect our
patient's health and happiness. Reputation, pleasing friends, making
a brilliant display of our activity, the saving of valuable time for rest
or profit, are none of them valid excuses for unnecessarily hastening
this process to the ultimate detriment of those who rely upon our skill,
our knowledge, and our candor in this hour of woman's greatest pain
and peril.

TRANSACTIONS.

CLINICAL SOCIETY OF THE NEW YORK POLYCLINIC.

STATED MEETING, APRIL 2, 1906.

The President, JOHN J. MacPHEE, M. D., in the Chair.
Reported by FREDERICK C. KELLER. M. D., Secretary.

REPORTS OF CASES.

TUBERCULOSIS OF THE CARPUS.

Doctor Victor C. Pedersen : I wish to present this patient, a
young woman who has suffered from tuberculosis of the wrist for
many years. Several years ago a palmar operation was performed in
a small town up the state, but there are no evidences that tuberculosis
ever existed in the hand. Two years ago the wrist was operated on,
a median incision being made, and a year ago two lateral incisions were
made. The wrist is now free from pain, and except for the ankylosis
of the joints which followed the first operation, there is no difficulty
in using the wrist. In dealing with tuberculosis of the wrist, an oper-
ator often forgets the diverticulum of synovial tissue which passes
upward between the radius and the ulna. At the last operation per-
formed upon this patient, it was at this point that the first foci of
tuberculosis was found. The largest synovial pouch passes forward
between the surfaces of the metacarpal bones, and here was found the

CLINICAL SOCIETY. 215

second foci. Both foci were removed and the patient recovered. As
a matter of precaution, she is wearing a metal splint while performing
her household duties. The ankylosis of the fingers is the result of the
operation performed four years ago, and nothing seems ot correct it.

GUMMA OF THE FRONTAL BONE,

Doctor Pedersen : I also wish to present this patient. I first saw
this man last summer, eight weeks after he had received a violent blow
on the head. At that time there was a tumor, which was supposed to
be an adenoma, partly chancroidal, partly syphilitic. It traveled down
under the skin, down into the fatty tissue, eating out large masses of
the tissue, and finally was stopped by bromidia water. Soon after the
lesion on the head broke and took on the characteristics of a specific
lesion and was dressed surgically. There seemed to be a fissure in
the skull, which had been previously treated, and exfoliation of the
bone took place. There was no temperature except that which would
naturally accompany anemia. At one time the lesion was thought to
be tubercular, but recovery under specific treatment seemed to confirm
the diagnosis of gumma with profound anemia.

DESTRUCTION OF TISSUE AND NAILS OF FOOT,

Doctor Pedersen : I will also present another patient, who came
to the House of Relief two weeks ago, having been discharged from
one of the city hospitals. The nails of the left foot and the tissue sur-
rounding them showed evidence of great destruction, and there was a
great deal of pus. The interesting question was whether to apply blue
ointment or a wet dressing. The patient's conditions of life made it
impossible for him to obtain any benefit from a wet dressing, so blue
ointment was used, with beneficial results. The foot presented an
appearance very similar to nephritis, but the other foot is not at all
swollen.

VARICOSE VEINS,

Doctor Alexander Lyle : I desire to present this patient, a man,
forty-eight years of age, who suffered from scarlet fever and whooping-
cough as a child, and from typhoid fever when twenty-eight years of
age. He is a heavy smoker and beer drinker. His present trouble
dates back twenty years to swelling of the ankles. The veins of the
right leg ulcerated several years ago, and a diagnosis of varicose veins
was made. The ulcers are very large in both legs, but cause the
patient no discomfort. I am of the opinion that at the time of the
typhoid a thrombus had formed in the injured vena cava, and the
superficial veins had taken up the circulation. No abdominal tumor
can be located, and the veins all originate above the brim of the pelvis.

NEPHRECTOMY.

Doctor F. C. Yeoman : I wish to report the case of a man, aged
fifty-six, who has been a heavy consumer of alcohol. About seven
months previous to operation he was seized with a severe pain in the

216 ORIGINAL ARTICLES.

right groin, shooting downward to the groin and corona glandis, and
the next day passed blood clots in his urine, but never passed any
gravel to his knowledge. During the next three months he had
attacks resembling renal colic at intervals of from two to five weeks,
passing clots but no stones. During the past two months he had suf-
fered severe intermittent pain during the night, beginning in the hypo-
chondrium and extending over to the midline; also intermittent pain
referred to the knees, more marked on the right side. The urine of
late has been free from albumin and never showed any crystals. The
patient's strength gradually diminished and he lost about forty-five
pounds in weight. No tumor could be felt seven months ago, but dur-
ing the past three months a mass gradually increasing in size has occu-
pied the right hypochondrium. Patient would not permit cystoscopy.
He was admitted to the Polyclinic Hospital February 15, demanding
operation for the relief of intolerable pain, although he had refused all
previous suggestic^s of surgical interference. His lungs, on physical
examination, were found to be normal ; heart-sounds soft, no murmur ;
radials moderately thickened. The abdomen was relaxed and the upper
limit of liver dullness diminished one intercostal space. The right
hypochondrium showed a tumor ovoid below, descending on deep
inspiration to a position opposite the umbilicus. On pressure it took
the position occupied by the normal kidney. Blood examination
showed a white count of eight thousand, hemoglobin, one hundred per
cent.

A right nephrectomy was done on February 20. The operation
was difficult, as the kidney was about three times the normal size, cov-
ered with a network of veins, and adherent on all sides. The wound
was closed, except for cigarette drains at angles. The time of opera-
tion was one and one-half hours, and the patient rallied fairly well;
but the following two days there was almost total suppression of
urine, only two ounces being secreted. Thereafter his condition
improved, and he secreted about the same amount and character of
urine as before the operation; but at the end of a week he began to
fail, and died on the eighth day. Autopsy was refused, and thus the
opportunity of discovering if metastases had occurred was lost.

A cursory review of the reported cases of hypernephroma warrants
the following tentative conclusions: Metastases is the rule, especially
to the liver, lungs and bones. These tumors have a tendency to spread
and involve veins, but no lymphatics. The renal brim is usually
involved, and sometimes the cava, but does not obstruct sufficiently to
cause edema of the extremities. In a few cases the growth long
remains local and can be successfully removed. Clinically, the symp-
tom that may be of diagnostic value is bleeding and its results. Tumor
and pain are present as in several other renal affections. Periodic
attacks of hemorrhage, with frequency of micturition, often with pas-
sage of clots, seem characteristic. These clots sometimes block the
ureter, cause diminished urine, and the pain is referred to the corona

CLINICAL SOCIETY. 217

glandis. Between the attacks of bleeding there is fairly constant pain
in the back. A fresh hemorrhage relieves the pain, thus contrasting
with pain and bleeding connected with the passage of stone.

PATHOLOGIC SPECIMENS.

Professor J. H. Larkin, of Columbia University : I shall present
some pathologic specimens of great interest and give the history of
each, insofar as I have been able to obtain it. The first are of diseased
appendages, a field of surgical research which is becoming more and
more important. Until a few years ago it was supposed that lesions of
the pancreas, as found at postmortem examinations, were fairly well
understood, although little was known of the etiologic significance;
but now pathologists are able to show the causative factor. Its close
relationship to cholelithiasis and other diseases of the intestinal tract
has been understood for some time. The clinical histories in these
cases are very similar. There is usually a severe onset of gastric pain
that at times is almost diagnostic to the surgeon of appendicitis or
intestinal obstruction, apd many patients have been operated on for one
or the other of these conditions. In the majority of cases, stone in
the ampulla duct has been a very common factor. The specimen which
I present is mounted so as to preserve its normal color. On the right
side is a portion of the duct and on the left a portion of the pancreas.
It is presumed that one or more stones had been passed in this case,
because of the immense dilatation of the common duct. The lesion is
easily explained, and experiments have reproduced exactly the same
condition. The stone passes down into the common duct and is
impacted at Bardes' ampulla, and this leaves a continuous passage from
the common duct to the ampulla, and the bile, instead of going down,
is sidetracked and goes directly into the pancreas, and this produces
hemorrhagic pancreatitis. This can be reproduced by putting bile into
the pancreatic duct, or a solution of hydrochloric acid will produce the
same result.

The next specimen shows the connection of the pancreas with the
duct, and also shows the gall-bladder with an immense amount of
stone. Of the several interesting brain specimens which I present, no
clinical histories could be .obtained. One specimen is from a patient
who had been under observation for some time, and whose condition
had been diagnosed as cerebral abscess. The specimen shows one side
of the brain, with the cerebellum and one cubic centimeter of hemor-
rhagic blood which was removed at time of operation.

EXHIBITION OF INSTRUMENTS,

Doctor J. E. Fuld : I wish to present this intestinal depressor. I
devised it for the purpose of depressing the intestines to prevent them
from extruding into the abdominal wound and interfering with the
operator. Gauze pads are usually inserted to overcome this difficulty.
The instrument has proved of value in pushing aside not only the
intestines, but the other abdominal contents as well, thus affording the

218 ORIGINAL ABSTRACTS.

Operator a full view of the area to be inspected. The instrument is of
polished steel, and shaped something like the ordinary glass tcfigue
depressor, being eight inches long, one and one-half inches wide at
one end and three-quarters of an inch wide at the other.

ORIGINAL ABSTRACTS.

MEDICINE.

By GEORGK dock, A.M., M. D., D.Sc. Ann Arbor, Michigan.

PKOPB8SOK OF MBOtCINB IN TMB UmVUISmr OW MICHIGAN.

AND

DAVID MURRAY COWIE, M. D., Ann Arbor, Michigan.

COURVOISIER'S LAW: ITS VALUE IN THE DIFFEREN-
TIAL DIAGNOSIS OF OBSTRUCTIVE JAUNDICE.

MoYNiHAN, in the May issue of the Edinburgh Medical Journal,
contributes an article "On the Violation of Courvoisier's Law," from
which I abstract and rearrange what seem to be the most important
points.

The Law. — **In cases of chronic jaundice due to obstruction of the
common bile duct, a contraction of the gall-bladder signifies that the
obstruction is due to stone; a dilatation of the gall-bladder, that the
obstruction is due to causes other than stone."

Courvoisier's explanation of the contraction or sclerosis of the gall-
bladder is that stones had been present in the gall-bladder for long
periods; that their presence had caused recurring attacks of cholecys-
titis, and that, as a result, the gall-bladder walls had become thickened
and fibrous. The gall-bladder so affected, became by degrees more and
more shrunken, and at last was represented by a shrivelled mass of
fibrous tissue, its cavity was greatly reduced in size, or almost oblit-
erated, and the shrunken dense adhesions hid it from sight. Oft
repeated attacks of cholecystitis and peritonitis resulted in cicatricial
compression and cramping of the gall-bladder.

Confirmation of the law has been made by Ferrier of France, Mayo
Robson of England, and A. Cabot in this country. Moynihan cites a
few cases which are directly in violation of Courvoisier's law, but calls
attention to the fact that Courvoisier himself recognized that the law
may sometimes be flagrantly infringed, and agrees with those just
mentioned that in the great majority of cases that came under his own
observation, the law has proved to be correct, but like all other laws is
capable of infraction.

Moynihan sums up his short but very comprehensive paper by

VARICOSE VEINS. 219

giving the following chief circumstances in which the law may be
violated :

(i) Where there is a stone or a stricture in the cystic duct causing
hydrops or empyema, together with the acute impaction of a stone in
the common duct.

(2) Where there is a stone in the cystic duct pressing upon the
common duct.

(3) Where there is distension of the gall-bladder by an acute
inflammatory process, with obstruction of the common duct by stone.

(4) Where there is chronic induration of the head of the pan-
creas, with a stone in the common duct.

(5) Where there is malignant disease of the common duct at any^
part of its course, or cancer of the head of the pancreas, and a chronic
sclerosing cholecystitis.

The validity of the law is established in at least ninety per cent of
the cases in practice.

The value of the paper is in its suggestion for more careful differ-
entiation of cases presenting the symptom of obstructive jaundice.

D. M. c.

SURGERY.

By frank BANGHART WALKER, Ph. B., M. D., Detroit. Michigan.
rmovBStoM or sukgbkt and opskativb sukobrt in thb dbtkoit porroKADUATB SCHOOL OF mbdicinb;

ADJUNCT PKOFBSSOR OF OPBSATIVB SURGBRY IN THB DBTIIOIT COLLBGB OP MBOICINB.

AND

CYRENUS GARRITT DARLING, M. D., Ann Arbor, Michigan.

CLINICAL PROFBSaOB OF SUB6BKT IN THB VNIVICUrrT OF MICHIGAN.

TREATMENT OF VARICOSE VEINS.

Charles H. Mayo, M. D., of Rochester, Minnesota, in Surgery,
Gynecology and Obstetrics, April, 1906. Of the many operations
advised for the relief of varicose veins no one is suited to all cases.
Not only the superficial veins produce the symptoms but the deeper
veins are probably enlarged. The long or internal and the short or
external sapheni veins are the ones usually affected. These connect
at the knee and the internal also connects with the deeper veins at this
point. The internal extends from the saphenous opening to the ankle
and joins the external saphenous through the dorsal vein of the foot.
These veins contain a number of valves which aid in separating the
blood column. The internal vein is accompanied by the internal
saphenous nerve, and the external vein by the external saphenous nerve.

The cause of varicose veins is difficult, in many cases, to under-
stand. In some it may mean congenital defect in the vein walls, valves,
or enervation. In some cases pregnancy is given as a cause and in
others pressure of tumors or injury. Vocation oftentimes increases
the condition and symptoms. The condition may begin as early as
twenty years, but many years may elapse before disabling symptoms

220 ORIGINAL ABSTRACTS.

may appear. The symptoms, which are well known, consist of ^fullness
or weight of the leg with edema and pain. This may lead to pruritus
or eczema. Local hemorrhages are frequent and may lead to pigmen-
tation and discoloration of the skin ; or, the tissues may break down,
forming ulcers.

The so-called Trendelenburg phenomenon is tested by lifting the
leg while the patient is lying down, and when the veins are empty the
long saphenous is compressed above. The patient now stands erect
and the pressure is removed and if the veins fill from below the valves
are intact; and if the waves of blood descend the valves are useless.
A few cases may be relieved by a change of vocation or climate, others
are required to wear elastic supports such as bandages or stockings.
Operative measures for relief are as old as the history of surgery and
include ignipuncture with Paquelin or electro-cautery, cutaneous and
subcutaneous ligation which are now seldom used, injections of irri-
tants in and about the veins, multiple ligation and excisions, multiple
incisions with torsion, removal, or Trendelenburg's operation which
consists in ligating and removing a short section from the upper por-
tion of the long saphenous. The more recent methods are subcu-
taneous removal in suitable cases and nerve stretching. To test the
advisability of operation an elastic bandage is applied from the foot to
above the knee. If this bandage can be worn with comfort the oper-
ation should give relief as the pressure shows that superficial vessels
are not necessary to circulation of the limb.

The writer reports one hundred eighty-five cases operated upon,
many times operation including both limbs. A number of changes or
modifications have been made in the operation. To aid in the work a
ring vein enucleator and a pair of forceps, the end of which forms a
ring when closed, have been invented. This operation is described as
follows :

"The vein is sought for and severed in the upper third of the thigh.
The proximal end is ligated. The lower end is passed through the
ring of the enucleator or placed in the ring of the forceps, and clamps
are placed on the end of the vein. By a gentle pushing force, the vein
being held to make tension and the tissues steadied on either side by
an assistant, the ring or forceps is pushed down the vessel for six or
eight inches, tearing off the lateral branches, when the point of the
instrument is forced against the skin from beneath and a small incision
is made to the ring or forceps, which is pushed through the opening,
holding the vein like a thread in a needle's eye. The vein-loop is
drawn out of the opening and also from the instrument, which is
removed, rethreaded on the vein, and is pushed down to a lower point,
where a small incision is again made and the process of removal
repeated. The small lateral branches are torn off, and, as a rule,
have enough muscle structure to close themselves. Should the main
venous trunk break, a new incision is made below the knee, the vein

INFLUENCE OF FEEDING ON INFANT MORTALITY. 221

exposed and divided, and the enucleation made in both directions from
this point. Below the knee the branches are larger and the vein is
more adherent, being more superficial, so that a shorter distance must
be travelled. If it is found that calcareous deposits, sacculations, or
extreme weakness of the walls render the case unsuited to the enucle-
ation method, and this occurs in about ten per cent of the cases, the
principle of operation should then be changed to an open method,
undermining only the section by the knee. Hemorrhage is avoided,
first by position. An ordinary gynecologic standard is placed in
position, and the leg raised in straight or extended position and sup-
ported by the ankle. The position renders the limb partially bloodless,
and also secures elevation and accessibility of the field of operation.
Should any branches cause more than ordinary hemorrhage, it can be
checked by a pressure-pad held against the skin over the region from
which the veins were removed, or by small packs, which are left for a
few minutes in the incision from which it arises."

When ulcers are present the ulcerated area is excised and skin-
grafted. Eczematous areas are painted with compound tincture of
benzoin or an acetic solution of gutta-percha which acts as an antisep-
tic varnish. The leg is kept elevated for twelve days. Recurrence
may come from widening of collateral veins, formation of new veins or,
as is claimed, from the regeneration of the saphenous itself.

The dangers from operation are pulmonary' embolism. Sepsis is
rare, although a serious possibility, and difficult to guard against in
some cases with ulcer and eczema.

PEDIATRICS.

By ARTHUR DAVID HOLMES, M. D.,C. M., Detroit, Michigan.

INFLUENCE OF FEEDING ON INFANT MORTALITY.

HowARTH (Lancet, July 22, 1905), having investigated this ques-
tion in eight thousand three hundred forty-two children, says the death-
rate among the hand-fed was nearly three times as high as that among
the breast-fed and twice that of children reared on mixed feeding.
Among children who were first breast-fed and subsequently hand-fed
the death-rate was not so high as among the purely hand^fed, showing
the advantage accruing to children who have natural food supple-
mented by artificial, rather than an entire supply of the latter. Children
fed on condensed milk show a very high mortality, and children reared
on bread, rusks, arrowroot and other farinaceous foods come next.
His deductions are as follows : The use of sweetened condensed milk,
either whole or skimmed, should invariably be discouraged, and whole
unsweetened condensed milk only should be permitted where one is
satisfied that the milk is being used with a proper degree of dilution and
.with the necessary additions, as in the case of modified cow's milk;

222 ORIGINAL ABSTRACTS.

also that since the death-rate among children reared on patent foods
is, on the average, higher than among those fed on diluted cow's milk,
every attempt should be made to encourage parents to use the latter
food and to educate them to an appreciation of the necessity for the
additions to, and the dilution of, cow's milk to render it suitable for
infant's food. The addition of patent foods to the dietary of very young
infants is unnecessary, sometimes dangerous and always expensive.
Furthermore, it must not be forgotten that the risks to which hand-fed
children are exposed are considerably minimized by mixed feeding and
that therefore every mother who is unable fully to satisfy her infant
should be encouraged to continue to feed her child and to supplement
any deficiency by means of artificial foods, and that only in ease of
absolute necessity should resort be had to artificial feeding alone.

OPHTHALMOLOGY.

By WALTER ROBERT PARKER. B. S.. M. D.

rKOFBSSOIt OF OPUTUALHOLOGT IN THB UMIVBKSITT OF MICHIGAN.

HOW A LIGHT SHOULD BE PLACED FOR READING.

Cravath and Lansing, in The Electrical World, of January 6.
The general lighting of small living rooms and parlors, together with
the location of lights for reading in such rooms, is discussed, with
criticism of special cases. The writers note at the outset that the
general lighting of a small living room and the provision for reading
lights are so closely connected that they must necessarily be considered
together. They write :

"The reading light is the one that is likely to be used constantly
and has so much to do with the comfort and eyesight of members of the
family that it needs earnest consideration. There are three common
ways of obtaining a reading light. One way is to illuminate the
whole room so brightly that reading is easy in any part of it. This is
usually undesirable for two reasons: One is that the eye is likely to
tire more quickly in a room so brightly illuminated in all corners than
it would be if it had an opportunity to rest by looking from the lighter
to the darker parts of the room occasionally. The cost of lighting a
room so brilliantly as this makes it out of the question in the majority
of .rooms. We will, therefore, leave out of consideration this method
of securing a reading light and consider the second and third methods.
The second method is to use a lamp placed near the reader and fitted
with a globe or reflector which will concentrate nearly all the light on
the book or paper. If we do this, the reading lamp is likely to be of
little value in the general lighting of the room and we will have to
add other lights besides the reading lamp if the greater part of the
room is not to be in comparative darkness. The third method, which
is the one usually to be preferred where the greatest economy is an

LOCATION OF LIGHT FOR READING. 223

object, is to use the same light both for reading and for the general
lighting of the room by equipping the reading light with a globe or
reflector which will concentrate a considerable portion of its light
within the area in which it is desired to read and at the same time
allow enough light to radiate in all directions to give fairly good illu-
mination over the rest of the room."

The popular impression that a portable table lamp is better adapted
to reading than a lamp on a chandelier or bracket is regarded by the
authors as a misconception, such table lamps being merely an inheri-
tance from the days of the candle and oil lamps. They say :

"With electric light, usually much more satisfactory results can be
obtained with a properly equipped reading light on or suspended from
the chandelier or on a bracket on one of the side walls. The reason
for this is that it is impossible with a table lamp to secure a reflector
which will throw as large a proportion of the light where it is needed
for reading purposes as can be obtained from the proper reflectors on
chandeliers and brackets. Most of the electric portable stand lamps
throw the greater part of the light down on the table around the base
of the lamp, so that the readers sitting around the table get only a small
percentage of the light. If the portable stand lamp is used on a library
table where the readers place their bodes on the table each side of the
lamp its use is permissible, but such is not the usual condition.

"There is also considerable misconception as to the comparative
distance from the reader of a lamp located six feet above the floor on a
chandelier as against a lamp located on a table. The average person
who has never measured these distances is under the impression that
the lamp on the reading table is much nearer. As a matter of fact, the
distances are nearly the same. There is really for the majority of
cases only about one thing to be said in favor of an electric table lamp
for reading as against a properly equipped lamp on a chandelier or
bracket. This is that with the table lamp it is not as likely that a
reader will get the regular reflection commonly known as "glare" from
a page of white paper because the light comes so much from one side.
In reading underneath a lamp on a chandelier or bracket the reader
must turn the page at such an angle that he does not receive this glare
from the paper. This is easily done, but many people undoubtedly
suffer from this without knowing what is the trouble or taking pains
to find out. Since this glare of regular reflection is likely to be more
pronounced with electric light than with kerosene lamps, it is probable
that this is responsible for the preference that some people have for
oil reading lamps, even though electric light is available in the rest of
the house."

In advocating the use of reading lamps placed on chandeliers and
brackets rather than table lamps, the authors disclaim a desire to advise
trying to read with chandeliers arranged for the general illumination
of the room. Chandeliers to be used for reading lights should be
especially equipped for the purpose.

224 ORIGINAL ABSTRACTS.

OTOLOGY.

By R. bishop CANFIELD, A. B.. M. D., Ann Arbor. Michigan.

PKOrSSSOB OF OTOLARYNGOLOGY IN THB UNIVUSITY OF MICHIGAN.

AND

WILLIAM ROBINSON LYMAN, A. B., M. D., Ann Arbor, Michigan.

OBMONSTKATOS OF OTOLAKYNGOLOGY IN THB UNIYBRSITY OF MICHIGAN.

A CASE OF ACUTE MIDDLE EAR SUPPURATION, COM-
PLICATED BY LABYRINTHINE FISTULA AND
PARALYSIS OF THE ABDUCENS NERVE.

HiLL Hastings, M. D., in Archives of Otology, Volume XXXV,
Number I. Twenty cases of paralysis of the abducens nerve have
been reported. This case presented at re-operation a fistula through
the inner tympanic wall as the probable avenue of extension of the
infection. Gradenigo concluded that this syndrome of clinical symp-
toms is the result of a circumscribed simple serous leptomeningitis
localized about the tip of the pyramid and caused by the diffusion
of the infection in the tympanum generally through the tegmen
tympani.

The patient was a male, twenty-two years old, who had an acute
ear trouble following a head cold. The ear showed some purulent
discharge, sagging of the posterior superior canal and an inflamed
bulging membrane with a small perforation. Moderate mastoid ten-
derness, chiefly over antrum and tip. Some tinnitis but no dizziness or
other symptoms. A free incision was made in the membrane. Three
days later the mastoid operation was performed with no findings of
especial interest. After operation discharge and pain continued and
gradually increased though the mastoid wound was clean. There was
some dizziness and marked tinnitus. The membrane remained red and
bulging and was incised two or three times to offer better drainage.
On the twelfth day the patient complained of increased dizziness and
double vision. Examination showed marked diplopia due to paralysis
of the abducens. No other motor or sensory disturbance. As this
case was an acute one and the hearing had been normal a radical opera-
tion was deferred. As the paralysis continued and the pain and dizzi-
ness increased a radical mastoid operation was done on the eleventh day
after the appearance of the paralysis.

The tympanic cavity was found full of granulations and pus;
malleus and incus were normal. When the cavity was cleansed pus
could be seen coming from the inner tympanic wall in the recess of
the oval window apparently through that opening. The stapes was
not found. The fistula was found to lead inward for half a centi-
meter before bony resistance was noticed. The opening was enlarged
and the fistula swabbed out with bichloride solution. No other
necrosis of the tympanum was found. A Ballance flap was made and
sutured above; the posterior wound was left open. Facial twitching

TREATMENT ON MYCOSIS. 225

occurred during the operation due to injury to the horizontal portion
of the facial canal which formed the upper rim of the fistula.

After the operation the pain subsided. The paralysis gradually
passed off and the diplopia entirely disappeared in four weeks. The
slight facial paralysis passed off within a week. The discharge and
dizziness soon disappeared. The middle ear was grafted five weeks
later, the posterior wound closed and the patient made a good recovery.

The peculiar features of this case are :

(i) The involvement of the internal ear early in the course of an
acute suppurative otitis media.

(2) The avenue of infection was through the oval window.

(3) The cause of the abducens paralysis by extension of the
infection to the nerve sheath through the labyrinth seems probable on
account of its rapid subsidence after drainage of the labyrinth was
established.

(4) The prompt recovery after drainage was established suggests
that it was not necessary to remove the inner tympanic wall and com-
pletely curet the inner ear.

(5) The conclusion seems reasonable that the occurrence of abdu-
cens paralysis in acute suppurative otitis media means an inward
invasion of the infection, and when accompanied by the above men-
tioned symptoms operative rather than palliative treatment should be
applied to the tympanic cavity. R. b. c.

LARYNGOLOGY.

By WILLIS SIDNEY ANDERSON. M. D.. Detroit. Michigan.

AaSBTAMT TO TMB CMAIB OF LASTMGOLOGT IN THE PBTKOIT COLLBGB OF MBDICINB

THE ETIOLOGY AND TREATMENT OF MYCOSIS OCCUR-
RING IN THE UPPER RESPIRATORY TRACT.

Under the above title, Doctor John Sendziak, of Warsaw (Annals
of Otology, Rhinology and Laryngology, December, 1905), gives an
exhaustive review of the subject. He states that the following are
the particular varieties of mycoses met with in the upper respiratory
tract :

(i) Mycosis leptothricia : causative agent — leptothrix bacillus.

(2) Mycosis sarcinica : causative agent — ^a variety of the sarcina.

(3) Actinomycosis: the causative agent being the actinomyces.

(4) Mycosis aspergillosis : caused by various kinds of aspergillus.

(5) Mycosis mucorina: produced by certain varieties of mucor.
This, according to some authors, causing the so-called "black-tongue."

(6) Mycosis oidica (soor) : caused by the oidium albicans.

The etiology of mycosis leptothricia has not been positively decided.
There exists two principal theories: (a) The parasitic, and (b) the
chdmical theory. The advocates of the first theory believe that the

226 ORIGINAL ABSTRACTS.

causative agent is the leptothrix bacillus, while those who believe in
the second theory hold that the organism is merely incidental to chem-
ical changes in the secretions.

Mycosis leptothricia is relatively more frequent in females than in
males. It shows itself in the form of pearly white, hard tufts or spots
which are situated in the crypts of the faucial tonsils, the lingual tonsils,
and sometimes seen in the follicles of the posterior pharyngeal wall.
These tufts are strongly adherent to the adjacent tissue and are removed
with difficulty, leaving a bleeding surface.

The course of the disease is chronic, and the symptoms may be few,
or none at all. The most common symptoms are a scratching, pricking,
burning sensation in the throat, accompanied by a disagreeable sensation
of stiffness and fullness.

The most satisfactory treatment is the thorough use of the curet
or the galvanocautery to eradicate the disease. General tonics should
be given.

Mycosis sarcinica occurs in the upper respiratory tract on the
mucous membranes of the oral cavity in persons who suffer from
diseases of the lungs, pneumonia, bronchiectasis, gangrene, and espe-
cially in persons suffering from tuberculosis or typhoid. This parasite
is found on the mucous membrane of the tongue, as well as on the soft
palate, in whitish diffuse masses similar to mould. This form of myco-
sis is of no special importance, and general symptoms are lacking.

-Actinomycosis is more frequent in men than in women, and usually
runs a chronic course. The disease is common in cattle, and may be
transferred directly to man. The symptoms of actinomycosis of the
upper respiratory tract consist, in general, of very violent pains in the
region of the pathologic process. The disease is primarily located in
the oral cavity, on the alveolar process of the lower jaw, causing perios-
titis alveolaris. It may extend to the pharynx, producing great swell-
ing in the palatopharyngeal region, with whitish-yellow nodules iden-
tical in appearance to follicular abscess.

The prognosis is not favorable, especially if the internal organs
become affected by the metastatic processes.

The treatment of actinomycosis of the upper respiratory tract is
primarily surgical in nature. lodid of potassium internally seems to
do good.

Mycosis aspergillina in the upper respiratory tract is rarely seen
The cause of this is undoubtedly due to the peculiarity of these organs.
Persons working in tanneries, or those dealing in leather, are predis-
posed to this disease, as leather is an excellent medium in which the
development of the aspergillus occurs.

Mycosis mucorina in the upper respiratory tract occurs but rarely.
It appears in two forms: (a) Mycosis dependent on the mucor corym-
bifer, and (b) mycosis depending on the mucor niger — the more usual
form. The second form, the so-called "black-tongue," is not a rare

SPIROCH.€TA PALLIDA IN SYPHILIS. 227

condition. The clinical picture is a brown discoloration, or a hairy-
black condition on the posterior part of the papillae circumvallatae.

The treatment consists in the scraping away of the hairy material,
as well as the use of alkaline gargles.

Mycosis oidioa (soor, thrush) occurs usually in young children.
The infection takes place from ingested objects, from nipples, and less
frequently from the air, or the infection takes place through the phe-
nomenon of partus. Thrush occurs as small, round, white spots, with
small excavations in the center, easily removable at first, later, as the
disease progresses, more adherent. These spots coalesce irregularly,
forming a sort of membrane of dirty color, the underlying mucous
membrane being red and swollen.

Local cleanliness and general treatment is indicated in this disease.

DERMATOLOGY.

By WILLIAM FLEMING BREAK EY. M. D., Ann Arbor, Michigan.

CLINICAL rROFBSSOK OF DBKMATOLOGT AND STmiLOLOGT IN THB UNIVBKSITT OF MICHIGAN.

AND

JAMES FLEMING BREAKEY. M.D., Ann Arbor, Michigan.

ASSISTANT IN DBBMATOLOGY IN THB UN1VBB81TY OF MICHIGAN.

SPIROCH^TA PALLIDA (SPIRONEMA PALLIDUM) IN

SYPHILIS.

The Lancet of March lo contains a symposium on the spirochaetae.
The first article under the above title is concluded in the issue of March
17. In this, Theodore Shennan goes into the history and literature of
the search for the contagium of syphilis from the time of the sixteenth
century. His search of the literature on the spirochaetae has been
thorough. He records the works of Schaudinn and Hoffmann, and
describes the spirochaeta pallida and spirochaeta refringens, methods
of staining and differentiating.

Spirochaeta pallida has been found in surface lesions, indolent
buboes, in blood obtained by splenic puncture, in circulating blood in
secondary syphilis and in various lesions of the inherent syphilitic.
Levaditi considers congenital syphilis to be a spirillosis of the newly
born. Efforts to find the spirochaeta pallida in tertiary lesions have,
with rare exceptions, proved unsuccessful. In searching for spiro-
chaetae numerous preparations should be made owing to their unequal
and irregular distribution.

Kiolomenoglou and von Cube found and demonstrated various
forms of spirochaetae in nonspecific lesions. Hoffmann admitted their
great similarity but claimed that they could be morphologically or
tinctorially distinguished from the pallida. Hoffmann states that
those found in carcinomata have blunt ends.

Kraus and Prantschoff found that spirochaetae disappear from
excised tissues within six hours. This is interesting in view of the

228 ORIGINAL ABSTRACTS.

generally accepted clinical fact that syphilitic virus removed from the
body soon degenerates.

Levaditi and Petresco found spirochaetae readily and in considerable
numbers in the serum of induced blisters.

Rona found the spirochaeta pallida in six out of twenty healthy
women and in three out of eighteen healthy men. Similar results are
reported by others.

The syphilitic virus cannot pass through a porcelain filter.

Statistics of the findings of numerous authors are given.

Schaudinn found spirochaeta pallida constantly in seventy cases
and in tertiary lesions as granular resting forms.

Castellani and Wellman have found spihochaetae in yaws correspond-
ing closely to the spirochaeta pallida.

Various spirochaetae often much resembling the spirochaeta pallida
have been found in hospital gangrene, in noma, gangrenous tonsillitis,
vaccine pustule, carcinomata and various venereal and nonvenereal
conditions and in the bone marrow and muscular coat of the small
intestine from cases of severe anemias and carcinomatous lymphangitis.
These various spirochaetae, as a rule, may be differentiated by staining.

Attempts at cultivation have so far been unsuccessful, j. f. b.

NEUROLOGY.

By DAVID INGLIS, M. D., Detroit, Michigan.

PKOFKSOR or NBKVOVS AND MBNTAL DISSASBS IN THE DBTROIT COLLBGB OP MBOICINB.

AND

IRWIN HOFFMAN NEFF, M. D.. Pontiac. Michigan.

ASSISTANT PHYSICIAN AT THE BASTBPN MICHIGAN ASYLUM.

"THE MENTAL SYMPTOMS OF CEREBRAL TUMOR."

Doctor Phillips Coombs Knapp cites {Boston Medical and Sur-
gical Journal, April 5, 1906) the opinion of others on the relation
and frequency of mental symptoms in brain tumors, and g^ves his statis-
tics, which have proved to him that in ninety per cent of all cases of brain
tumor mental symptoms can be noted. He reiterates his statement made
some years ago that in every case some mental change can be found
by a competent observer who has known the patient before. In other
words : there can be no gross lesion in the brain without some disturb-
ance, greater or less, in the physical functions. He, however, modifies
the dictum to this effect : that in every case of brain tumor some mental
symptoms can properly be discovered, at least by a competent observer
who has known the patient intimately before. Regarding the nature
of the mental symptoms, Knapp says that his investigations agree with
those of Schuster. Schuster's statistics are dependent upon a series of
seven hundred seventy-five collected cases, and would indicate that

THERAPEUTICS OF LUPULIN. 229

while mental torpor and stupor are present in a greater proportion of
cases, specific psychoses are not infrequently found. Thus of his
seven hundred seventy-five collected cases, two hundred fifteen showed
mental conditions analogous to recognized forms of mental trouble.
The question of the relation of the seat of the tumor and the mental
symptoms is given considerable space by the author. The statistics of
collaborators are considered and a reference table comprising all of
the author's cases is given.

In conclusion he states that "in studying the early development of
mental symptoms I have already indicated the relative importance of
certain areas in the possible production of such symptoms ; but the fact
that mental symptoms m^y arise from a growth anywhere within the
cranium, forces upon us the conclusion that other factors beside the
location are of importance in their production." Knapp is unable to
find any relation between the nature of the growth and the form of
mental disturbance. He believes, however, that a rapidly growing
tumor will more speedily cause mental symptoms than one of slow
growth. He also infers from his study that "delirious" conditions are
more apt to occur in cases of sarcoma. Attention is called to the
resemblance between the mental symptoms met with in cases of brain
tumors to those occurring in toxic psychoses.

The writer believes that the cases under consideration reveal noth-
ing as to the nature or even the existence of these toxins, but it seems
probable that while the situation of the growth is often of influence in
producing mental symptoms, especially in the early stages of the dis-
ease, and possibly has an influence upon the nature of the symptoms,
a combination of increased cranial pressure and the action of the toxin
are of greater importance, and in some cases may be the only factor to
be considered in the production of such symptoms. i. h. n.

THERAPEUTICS.

By DELOS LEONARD PARKER, Ph. B., M. D., Detroit, Michigan.

LBCTVKBK ON MATKRIA IfBDICA IN THB DBTROIT COLLBGB OF MBDICINB.

THE THERAPEUTICS OF LUPULIN.

Doctor Thomas F. Reilly (The Journal of the American Medical
Association, April 7, 1906) discusses the therapeutics of lupulin as
brought out by an investigation made by himself and H. Stern, M. D.,
of New York. At the outset the statement is made that the purpose of
the paper is to bring into view some of the old, and also some of the
new, properties of one of the oldest agents in the materia medica.

Attention is called to the circumstance that formerly lupulin was
looked upon as almost a specific for scrofula, struma and the various
skin diseases.

230 ORIGINAL ABSTRACTS.

Lupulin is derived in the form of scales from the hop plant. These
scales contain lupulinic and humilic acids and a volatile oil. The taste
of the drug is bitter. This is caused by amorphous hop resins rather
than by alkaloids. Lupulin to be of value must be derived from the
best Bohemian hops. It must also be fresh and have undergone no
exposure to light or heat.

The active principle of lupulin is closely related to valerianic acid.
Taken by the mouth lupulin causes a sense of warmth first in epigas-
trium and later over whole abdomen. It is a mild diuretic and in some
persons lowers the pulse rate from ten to twenty beats a minute. The
properties of the drug to which Doctor Reilly desires particularly to call
attention are its hypnotic and anodyne properties. In twenty-grain
doses repeated in a half hour it has a strong tendency to produce sleep
and also to relieve nervousness, particularly that following excesses.

As a pain-relieving agent it is to be classed with the milder anodynes.
This property makes it of value in the colics of children, in acute pros-
tatic disease and in neurasthenia and hysteria. It is also of value in
headache, especially of the occipital variety, and in the pains of menstru-
ation when not caused by pathologic lesions.

In its administration aromatic spirits of ammonia forms a good
vehicle for a liquid preparation. It may also be mixed with sugar when
it is given to children. Generally, however, it is best administered* in
capsules. It can be substituted for opium in treating children and for
the coal-tar products in many instances. Indeed, its property of meet-
ing the conditions wherein a coal-tar product is often thought to be
indicated is considered by Doctor Reilly to constitute its chief claim to
the attention of the profession. This view is shown by the following
quotation taken from the closing portion of this paper :

"In this era of a high-tension civilization the practitioner is not
infrequently brought face to face with the treatment of pains and aches
and insomnias which are not in themselves severe and do not have any
organic disease as a cause. These patients are neurotic and high strung
and are not suffering enough to demand the use of an opiate, and yet
in these very people habits are easily formed. The coal-tar series of
the past decade has seemed the surest way out of such a dilemma. The
laity know it as well as we do and act accordingly. Now that the
formation of a coal-tar product is generally recognized, it will probably
be a major problem in the next generation. Any one who has seen the
cyanosis, palpitation, et cetera, following the use of any of these agents
in some people must conclude that they are not in any case without
some harm, however slight it may be. In many of the cases described
above in which we are tempted to use the coal-tar series, we may sub-
stitute lupulin and we may go home and sleep soundly, confident that
the patient will have been, in a measure, relieved and that he will not
be found dead in bed the next morning as has not infrequenty happened
when an acetanilid powder has been taken to soothe his nervous
complaints."

CONGRESS OF PHYSICIANS. 231

EDITORIAL COMMENT.

THE PORTUGUESE INTERNATIONAL CONGRESS OF

PHYSICIANS.

Lisbon afforded every desideratum to render the recent Fifteenth
International Medical Congress a complete scientific and numerical
success barring the Latin tongue and a lack of delegates. The former
militated against a cosmopolitan participation in the discussional work
of the sections, while the latter essential was not in evidence to marked
degree, registration showing the presence of only about sixteen hun-
dred, fifty of whom were from the United States. The idea of two
successive Latin congresses was not calculated to insure international
attendance, and a practical test of the experiment has demonstrated
that the delegates hailed principally from Portugal, Spain, and other
countries in which the vernacular contemplates Latin derivation.

* * *

The Congress was convened by King Carlos on Thursday, April
19, and continued its sessions through the week ending April 26, the
address of welcome, an interesting discourse, being read by His
Majesty in French. The speaker was supported on either side by
Queen Amelie and the Queen Dowager, the former, by the way, being
a regular physician, a trained nurse, and one of the most intellectual
women of the age. The general addresses reflected the present status
of practical medicine and surgery. Aaser, of Christiania, detailed the
"Relations of Acute Infectious Diseases With Tuberculosis"; Boyce,
of Liverpool, discussed "The Prophylaxis of Yellow Fever as the
Result of the 1905 Epidemic in Central America and New Orleans;
Brissaud, of Paris, talked on "Infantilism"; Crocq, of Brussels,
described "The Mechanism of Reflexes and of Muscular Tonus" ; von
Hansemann, of Berlin, revealed "The Significance of Domestication
for Diseases of Animals and Man"; Neumann, of Vienna, related
"The Anatomic Causes of Syphilitic Relapses and Methods to Follow
to Combat Them" ; Reclus, of Paris, discoursed on "Local Anesthet-
ics" ; de TarchanoflF, of Saint Petersburg, recounted the possibilities of
"Radium in Biology and Medicine, or Organotherapy of Our Days" ;
while our own Senn, of Chicago, made "A Plea for the International
Study of Carcinoma." The programs of the twenty different sections
afforded abundant material for consideration, in fact more than could
be properly discussed during the sessions notwithstanding many of the
titles listed were unsupported by paper or author. The total number
of essays and addresses announced was two hundred fifty, representing
one hundred forty different subjects, but comparatively little very new
was added to our store of knowledge. The operation of Gigli, cutting
the iliac bone, was offered as a substitute for symphysiotomy. Frank

232 EDITORIAL COMMENT.

recommended a suprapubic, extraperitoneal Cesarean operation, claim-
ing superiority for this procedure, especially in septic cases. The
American operation for fibroids received endorsement. Discussion
concerning yellow fever elicited expression of doubt as to mosquitoes
being the only cause of the scourge. Tuberculosis received attention
commensurate with the importance of the subject, Bernheim urging
the appointment of an international prophylactic commission to draft
a code of regulations bearing on the disease.

♦ ♦ ♦

The social features of the event were numerous, some being
decidedly elaborate. The various functions included receptions, din-
ners, garden parties, excursions, bull fights, et cetera. The dinner
tendered by the King was a brilliant affair. It was attended by one
hundred fifty official delegates, court officials, and ambassadors, who,
together with the King, Queen, Queen Dowager, diplomats, and mili-
tary officers increased the number to two hundred. The American
delegates were tendered a dinner by our representative at the Court of
Lisbon, Charles Page Bryan, covers being spread for fifty guests.
The King and Queen gave a garden party in the royal grounds, and
the Marquis of Montserrat treated the guests to another garden party
in his grounds at Cintra, while a reception was tendered by the city
of Lisbon at the Hotel de Ville.

The next meeting will be held at Budapest three years hence, the
Hungarian invitation having been backed by a governmental appro-
priation of fifty thousand dollars.

ANNOTATIONS.

THE TREATMENT OF CANCER WITH TRYPSIN.

Probably no disease is fraught with more disastrous consequence
than cancer. Although the medical treatment of the malady has hith-
erto been of a somewhat empirical nature, the result of recent experi-
ment would seem to indicate that the etiology and therapy of the
growth will soon be known factors. Speculation bearing on the cause
has given rise to both humorous and scientific theories, and among
the latter that of Beard, of Edinburgh University, seems sufficiently
meritorious to elicit comment. Beard contends that migrating cells
exist in all parts of the organism and that under normal conditions
they are merged with the fixed cells of the body. However, in certain
disease conditions, from causes at present undetermined, the wanderer
fails to unite with a fixed cell, thus becoming foreign and producing
the malignant growth — cancer. This view is a slight modification of
Cohnheim's theory, but Beard has augmented the hypothesis by ven-
turing the assertion that the growth may be directly traceable to the

RACE SUICIDE. 233

absence of some systemic product — a substance which is calculated to
destroy the malicious nature of the aberrant cell and convert it into
normal tissue. Beard being an embryologist, has had abundant oppor-
tunity to study various forms of life in developmental stages, and has
observed that immediately upon the establishment of the pancreatic
function in fishes the wandering cell disappears. Using this phenome-
non in the fish as a possible clue upon which to establish a logical treat-
ment, Beard employed trypsin in cancerous mice with apparent good
result, the wandering cell disintegrating and leaving the normal cell
unimpaired. The product has been used to some extent on human
l>eings with the idea of preventing recurrence of the disease after
operation, and from all appearances the effect has been gratifying.

THE DEMISE OF PROFESSOR CURIE IN PARIS.

Professor Curie, who with his wife shared the honor of giving to
science a new chemical element — radium, died on April 19, from
injuries sustained in a collision with a vehicle in the streets of the
French metropolis. Curie married a Polish woman/ a profound stu-
dent of science, who had been a worker in his research laboratory, and
after six years of conjoint and untiring labor their discovery of radium
was announced in 1898. The nature of the element upset some of the
supposedly fixed chemical hypotheses such as the atomic theory and the
theory of the conservation of energy, and the enthusiasm of certain
therapeutists for a time gave the product undue prominence in the
domain of medicine. In 1903 Professor Curie received, in conjunc-
tion with his wife, the Nobel prize for scientific research, and in the
same year Madam Curie was awarded the Osiris prize of $12,000.
That the usefulness of radium and many of its properties had not been
determined. Curie was convinced, and he was deeply absorbed in
research at the time of his premature demise. In his death the world
lias lost a man of vast scientific attainment and one who was calculated
to revolutionize certain fields of science. A widow and child eight
years old are immediate mourners.

DOCTOR REED ON RACE SUICIDE.

Contrary to the views of President Roosevelt on the race suicide
' -question, are those of Doctor Charles A. L. Reed, of Cincinnati, who
argues that few children properly reared will better subserve the
common weal than many children developed in unsuitable environ-
ment, the idea being that conditions of creature are paramount to
commands of creator. In the course of a lecture on the "American
Family" the doctor said: "We see in a declining birth-rate only a
natural and evolutional adjustment of race to environment — an
adjustment that insures rather than menaces the perpetuation of our
kind under favoring conditions." Race suicide consequently implies.

234 EDITORIAL COMMENT.

according to the speaker, not aversion to conception, but an unselfish
regard for the proper development of the offspring. Continuing,
Doctor Reed said: "American women recognize, subconsciously, pos-
sibly, certainly not in definite terms, but they nevertheless recognize,
the force of the law enunciated by Mr. Spencer that whatever conduces
to the highest welfare of offspring must more and more establish itself,
since children of inferior parents reared in inferior ways will ever be
replaced by children of better parents reared in better ways."

CONTEMPORARY.

•PHYSICIANS AND PHILOSOPHERS.

[PKOFBSSOR CHARLBS WILLIAM SUPBK, OP OHIO UNIVBRSITY, IN POPULAR SCIKNCB MONTHLY.]

{CoHiiHU*d from page qi.)

It will scarcely be denied by those best qualified to judge that of
the three learned professions that of medicine is still the best fitted
to stimulate thought and investigation. It is less hemmed in by
tradition, and is of immediate public interest. The man who conquers
a dangerous disease or who performs a difficult surgical operation
needs no other endorsement. Unless he allows avarice to draw him
into a practice more extensive than his constitution will bear, he will
have a fair degree of leisure for liberalizing his mind by the study of
subjects outside of his particular sphere. The history of modem
times no less than that of antiquity offers many examples of medical
men whose interests were almost coextensive with those of mankind.
That the physician, the investigator, the philosopher and the litterateur
may be happily blended in one person is finely illustrated by the latest,
though it is to be hoped not the last, volume either of the man or of
his kind, the *Aequanimitas' of Doctor Osier.

No one who is acquainted with human nature will be surprised
when he learns that the class of medical practitioners known as
'quacks' flourished among the comparatively enlightened Greeks of
ancient times. Often, however, the quack is one who strives after
results by a method that has been tabooed by the corporation to whose
regulations it is assumed that he ought to have subscribed. Though
he is an outlaw, before the tribunal of mortals he may be just as good
as if he were an in-law. That mysterious and apparently inscrutable
part of our being known as the nervous system has always presented
problems which medical practitioners have been unable to solve. Why
should not a faith-cure be as legitimate as any other cure, provided it is
genuine? And there have been faith-cures time out of mind. When
persons cannot control their own imaginations, the task would seem to
be doubly difficult for any one else. Often the most important part
of the physician's business is to arouse in his patient the will to get
well, and whatever will accomplish this cannot be stigmatized as fraud.

PHYSICIANS AND PHILOSOPHERS. 235

When hope is lost all is lost. I have known not a few persons who
died because they did not want to live or were at least indifferent ; and
probably an equal number who materially lengthened their lives by
the mere determination not to die. My attention was drawn to this
phase of pathoIog>' many years ago by a curious incident that came
under my observation when I was a mere lad. I did not hit upon the
explanation until long afterwards. I have seen the same thing
repeated many times since then. A vender of medicaments of his own
concoction used to visit our neighborhood about twice a year. One
day as he was driving along he began to feel unwell, and, contrary to
the proverb that doctors never take their own medicines, picked from
fiis chest a vial containing what he believed would afford him relief,
and drank some of its contents without looking at the label. Having
occasion shortly afterward to leave his wagon to visit one of his cus-
tomers, it occurred to him that he had drunk from a bottle containing
a strong poison. He at once began to feel very sick. A sort of stupor
seized him and he became so weak that he could hardly walk. As
soon as he could get back to his medicine-chest he looked at his bottles
again, when, to his great joy and greater relief, he found that he had
taken just what he intended. The man declared afterwards that he
believed he would have died if he had not had the means of ascertain-
ing the facts in the case.

Though the ancients knew little of the structure of the nerves, they
were well aware of the influence of the imagination as a therapeutic
agency. The walls of many of their temples were covered with tablets
and votive offerings in testimony of gratitude to the god by whom the
sick were healed. Faith-cures and christian science are therefore by
no means a new thing under the sun, but something very old under
new names. Though the ancients rarely, or not at all, dissected
human bodies, they had a fairly definite knowledge of anatomy derived
from the inspection of brutes. The bony structure could be readily
studied with the aid of the skeletons that were plentiful enough in
countries dotted with battlefields. The Persian invasion alone proba-
bly left tens of thousands of corpses strewn along the retreat of the
great king. The aversion to the dissection of cadavers that was felt by
many of the Greeks seems to have been connected with their reverence
for the human form. It was regarded as a sacrilege to mutilate even a
corpse. The treatment which the dead body of Leonidas received at
the hands of Xerxes was due, as Herodotus expressly informs us, to
the extraordinary exasperation he felt against the Spartan king for his
fierce resistance to the Persian advance. Though Achilles had dragged
the dead body of Hector many times around the walls of Troy, yet
Apollo preserved it uninjured. This reverence for the *human form
divine,' like many others superstitions, interfered seriously with the
progress of science. The favorite gods, Zeus and Apollo, were repre-
sented as physically perfect men. The effects of this sentiment are
especially evident in the manner by which those condemned to death
were executed. There seems to be no other explanation of the singular

236 MEDICAL NEWS.

custom of administering the hemlock juice than the desire to leave the
body after death as nearly as possible as it appeared in its living state.
That the rule was departed from under special circumstances and in
times of great excitement is no valid argument against the correctness
of the explanation.

[TO Bl CONTINUBD.]

MEDICAL NEWS.

A GRIST OF MEDICAL GRADUATES.

The thirty-eighth annual commencement exercises of the Detroit
College of Medicine were held in Light Guard Armory, Thursday even-
ing, May 17, 1906, when eighty-two candidates received the degree of
Doctor of Medicine. The address of the occasion, which will be pub-
lished in the next issue of this journal, was delivered by Doctor Frank
B. Walker. After the award of diplomas a banquet was tendered the
graduating class at Hotel Cadillac by the Faculty of the College. Fol-
lowing is a list of those upon whom degrees were conferred : S. M.
Angle, O. Amdt, A. W. Blain, Jr., G. K. Boyajian, G. T. Britton, C. W.
Burge, J. F. Burleson, R. C. Burt, J. B. Chapman, R. L. Clark, C. W.
Courville, F. L. Covert, R. E. Dawson, W. A. DeFoe, P. J. De Free, W.
H. Dunham, G. A. Easton, O. A. Fischer, E. F. Fisher, F. G. Fisher, H.
I. Flanders, R. R. Fox, H. E. Eraser, F. D. German, G. C. Griffis, J. L.
Hammond, T. P. Hanna, J. H. Hanson, H. Harrison, L. L. Harrison,
W. H. Haughey, Jr., L. E. Hemenway, J. H. Henry, C. F. Hinchman,
W. Hipp, M. C. Hubbard, E. R. Johnston, W. G. Kanter, J. C. Ken-
ning, H. I. Kedney, J. E. King, J. A. Klahs, B. G. W. Larke, R. W.
Luce, J. F. McKay, J. C. MacKenzie, J. R. MacKenzie, C. L. D. Mc-
Laughlin, A. R. Miller, F. B. Miner, L. Mueller, F, E. Murphy, C. H.
Oakman, H. A. Osborn, H. A. Ott, W. C. Pepin, H. Pepper, M. E.
Pickens, A. C. Potter, A. D. Potter, F. A. Pratt, S. W. Randoph, C. J.
Rolhnan, D. U. Saunders, F. M. Singer, C. A. Smith, W. H. Snyder,
R. E. Spinks, U. G. Spohn, C M. Stafford, T. C. Starrs, F. E. Stevens,
H. A. Stewart, C. H. Stiles, J. E. Strain, F. M. Summerville, R. S.
Taylor, F. Tremblay, E. C. Van Sickle, J. R. Van Sickle, W, J. Voor-
heis, F. T. Zieske.

MINOR INTELLIGENCE.

The alarming increase of pneumonia in Indiana, and the large
number of deaths incident to the disease, has instigated the issuance of
a bulletin by the State Board of Health calling the attention of physi-
cians to the prevalence of the affection, and admonishing them to
instruct the laity as to its seriousness and the best means of combatting
the dissemination of the pneumococcus.

MINOR INTELLIGENCE. 237

Doctor Emma Cook, a prominent women practitioner of Detroit,
died of anemia on April 14, aged fifty-eight years. Doctor Cook was
a graduate of the University of Michigan, with the class of 1892.

A MEMORIAL service was held in Berlin on April i, to commem-
orate the death of Doctor Max Nitze, the inventor of the cystoscopy
An exposition has also been conducted showing the various stages of
development in the instrument, and the material originally employed
by Nitze.

The American Gastroenterologic Association will meet in Boston,
June 4 and 5, 1906. The president's address will be delivered by
Doctor Henry W. Bettmann, of Cincinnati, on "The Mutual Obliga-
tions of the Surgeons and Internists in the Proper Development of
Gastric Surgery."

The Ohio State Medical Society met at Canton on May 9, for a
three days' session. An interesting and instructive program was pre-
sented. The oration in Medicine was delivered by Doctor John C.
Hemmeter, of Baltimore; and that on Surgery by Doctor Harvey C.
Gaylord, of Buffalo.

Verily, this is an age of remarkable progress in medical thought
and practice. A contemporary reports the case of a sightless Wash-
ingtonian, to whom were transplanted the eyes of a Belgian hare. The
operation is said to have been so skilfully performed that vision was
completely restored!

Professor van Ermenghem^ of Brussels, recently announced
before the Academy of Medicine that he had proven almost conclu-
sively the bacterial origin of cancer, and further stated that the results
obtained in a long series of experiments have led him to the belief that
serum derived from the organism will cure the disease.

Doctor Edward Anthony Spitzka, formerly connected with the
Philadelphia College of Physicians and Surgeons as demonstrator of
anatomy, has been elected to the professorship of general anatomy
in the Jefferson Medical College. Doctor George McClellan will
occupy the chair of applied anatomy at the same institution.

The Christian Hospital, of Chicago, an institution of undetermined
reputation, was recently fined $250 for publishing, without sanction,
the name of Doctor John B. Murphy as president of its executive board.
The hospital authorities persisted in their employment of the name,
regardless of the fact that Doctor Murphy secured an injunction
restraining them from so doing, hence the penalty.

Over a million circulars of warning have been distributed during
the past two years by the German Society for the Prevention of Vene-
real Disease. The campaign has been very thorough, physicians, dis-
pensaries, and the army being the agencies through which the dis-
tributions were effected. It is the purpose of the society to issue a
similar circular to women and young girls during the coming year.

238 MEDICAL NEWS.

Smallpox has wreaked havoc in Chile during the past year, the
country having been literally infested with the pest. Since January,
1905, more than eleven thousand cases and five thousand deaths have
been recorded — a powerful argument against the existing sanitary
regime of the South American republic.

Andrew Carnegie has deviated from the path of library endow-
ment by promising the sum of $10,000 to the College of Physicians
and Surgeons, of Atlanta, Georgia. The college trustees are desirous
of raising $100,000 for the purpose of erecting new buildings, and the
steel magnate's gift will be the last $10,000 of this amount.

New York is suffering from an epidemic of diphtheria, and new
cases are daily recorded. The percentage of deaths from the disease
has become so high that Health Commissioner Darlington has issued
an appeal to both laity and profession for a more generous employment
of antitoxin. At present the death rate is fourteen per cent.

The commission in charge of the Michigan Sanatorium for Con-
sumption has chosen a site two and one-half miles from the city of
Howell. The location is an ideal one, since it possesses excellent nat-
ural advantages, being at an elevation of one thousand one hundred
feet above sea level, and having running water, timber and a lake.
The property, one hundred ninety acres, was presented by the city of
Howell.

A committee composed of American and European physicians has
been formed to solicit and receive subscriptions for the erection of a .
monument to the late Surgeon Miculicz-Radecki, of Breslau. W. W.
Keen, of Philadelphia; W. S. Halsted, of Baltimore; J. B. Murphy, of
Chicago; and F. Kammerer, of New York, comprise the quartet of
Americans who will represent the work in the United States and
Canada.

The establishment of a new filtration plant in connection with the
Jerome Park reservoir, New York, is being agitated, the city com-
missioner having submitted preliminary plans to Mayor McClellan.
The present move was instituted to offset the plans of a rival faction,
whose idea contemplated the purchase of a new site, which, together
with the cost of building the filter, would indebt the city to the extent
of $8,500,000, according to a very low estimate. The plan of the
present projectors is to utilize the park property for the enterprise.

The consolidation of the Medical College of Indiana, the Central
College of Physicians and Surgeons, and the Fort Wayne School of
Medicine has been effected, and the trio will henceforth form a com-
ponent part of the Purdue University at Indianapolis. In a circular
announcing the change, the executives of the several colleges explain
the reason therefor by stating that a concentration of interests in a city
of sufficient size to offer ideal clinical facilities will best conserve the
interests of all concerned — students and teachers alike. The consolida-
tion was effected after an agfitation covering a long period of years.

DIFFERENTIAL DIAGNOSIS. 239

A WOOD alcohol debauch is responsible for one death and the serious
illness of several prisoners confined in the military prison at Governor's
Island. The product was undoubtedly secretly conveyed to the in-
mates by visitors. The deleterious results ensuing from the employ-
ment of wood alcohol, even in commercial pursuits, has led to the intro-
duction of several bills before the House Committee on Ways and
Means at Washington, for the removal of the internal revenue tax on
grain alcohol for industrial purposes. Painters and varnishers are
especially subject to the vapors of the wood product, and a chair
finisher who lost his eyesight from this cause appeared before the com-
mittee to support the measure.

RECENT LITERATURE.

REVIEWS.

DIFFERENTIAL DIAGNOSIS AND TREATMENT OF

DISEASE.*

If the title of this book is comprehensive, the contents are no less
so. This includes : "The Technique of Diagnosis and Laboratory Aids
to Clinical Diagnosis," 55 pages; "General Therapeutic Management,"
pages 55-87; "Pediatrics," 87-229; "The Digestive System," 229-332;
"Circulatory System," 33-409; "Respiratory System," 409-469; "Gen-
ito-Urinary System," 469-533; Osseous, Muscular and Articular
System," 533-602; "Infectious and Contagious Diseases," 602, 643;
"Diseases Due to Faulty Metabolism, Faulty Internal Secretions and
Derangement of Ductless Glands," 643-675; "Nervous System," 675-
769; "Dermatologic Memoranda," 769-806; "Otic Memoranda," 806-
812; "Ophthalmic Memoranda," 812-823; "Anesthesia, Intoxications,
Miscellaneous Ailments, Keeping Case Records and Accounts," 823-
838. This classification seems somewhat arbitrary, but may have some
practical advantages that have not made themselves apparent to the
reviewer. Similar reasons, probably, have placed "dysentery" in the
chapters on "Pediatrics and Digestive System," lobar pneumonia and
tuberculous pneumonia" in the "Respiratory System," et cetera. A
more orderly though less "practical" classification, with a good index,
would have answered the practical need just as much, and would almost
certainly have saved space.

As for the text itself, the author has acquitted himself well of a
task that at first sight seems almost impossible. That is, he has given
some directions regarding each of the numerous topics included in

240 RECENT LITERATURE.

his scheme. Necessarily these are brief, in many cases so brief as to
make the work more useful for hurried reference in an unexpected
time of need, rather than for thorough information, such as the prac-
titioner, or even the advanced student, should have. The views of the
author are on the whole sound, often admirable. The introduction
should be read by all who are preparing for the medical course. Other
indications of the high principals held by the author are often encoun-
tered through the text, and do not seem to suffer from occasional jux-
taposition with recommendations of remedies not yet admitted to the
"United States Pharmacopeia." In general, too, the directions for
diagnosis and treatment are sound, though lapses are not infrequent.
The author's tendency to look for and treat a malarial complication
takes one back to the preplasmodial days. His opinion of the value
of waxy casts — to indicate chronic rather than acute processes — is cer-
tainly wrong. In some of the technical directions haste has led to
omissions, sometimes important for beginners, as in the descriptions
of blood stains, page 44, the preparation of aniline water, and others.
Sometimes the omissions are tantalizing, as when we are told (page 52) :
"There are peculiar cell reactions so that we can determine which cells
come from primary and which from secondary tumors," without further
descriptions of the alleged reactions. Repetitions are notably frequent.
Antique beliefs are sometimes resuscitated, as in the assertion of the
diagnostic importance of Sanirelli's bacillus. lodophilia seems unduly
exalted and its history set forth with details that would gain by refer-
ences to original articles.

The directions for treatment are in the main good, but usually are
too brief for anything but momentary use. Typhoid fever has a little
over two pages ; pneumonia not much more than one page on treatment.

The work is profusely illustrated, but many of the pictures belong
to the realm of portraiture rather than medicine. If one must have a
cut of a stomach tube it would seem better to picture that sort in general
use. The cut labelled "bronchocele," and also the description, seem to
limit the use of that term to bronchial cyst, which is certainly not cus-
tomary. The position of the patient blowing bottles is not one that is
likely to further the result desired.

On the whole, while the plan and scope of the book are good, it
requires considerable alteration before it can be recommended for
undergraduates. For the practitioner who knows enough to avoid the
mistakes, it will be interesting; to others it might be dangerous if fol-
lowed blindly. It is to be hoped the necessary corrections may soon
be made, so that the work will all be as good as its best parts.

G. D.

*A Text-Book for Practitioners and Advanced Students. By
Augustus Caille, M. D. With two hundred and twenty-eight Illus-
trations in the text. New York and London : D. Appleton & Company,
1906.

% itesician aulr Swrgeon

A PROFESSIONAL MEDICAL JOURNAL.

VOLUME XXVIII. JUNE, 1906. NUMBER VI.

ORIGINAL ARTICLES.

ADDRESSES.

PRACTICAL DISCOURSE TO EMBARKING PHYSICIANS.*
By frank B. walker, Ph. B., M. D., Detroit.

AOJimCT ntOFBS60R OF ftUKGUlY IN THB DBTKOIT COLLBGB OF MBDICINB.

Mr. President, Associates on the Faculty, Members of the Graduating
Clctss, Ladies and Gentlemen:

It is now thirty-eight years since this college first opened its doors
to aspiring students of medicine. It is not long in point of time, but
from the viewpoints of work done and of medical progress, the vista
is broad and inspiring. Classes have come, pursued the round of col-
lege life, and gone, until already more than seventeen hundred and fifty
students have passed before the eyes of a critical faculty and taken up
the practice of medicine and surgery in thirty-nine of the United States
and in many places abroad. Think of the hours of study and the efforts
to teach which this army of trained men represent; calculate in your
mind the services of each alumnus and the sum total of them all in the
interest of life and health ; picture if you can the want of all this pro-
fessional skill, the kindly offices of all these devotees to duty, and then
will you not place a high and lasting regard upon the results achieved
through the instrumentality of this institution ?

Thirty-eight years ago medical education, in spite of a hoary past,

was in a very rudimentary stage of development. No one of us may

hope to see the science perfected, and yet those who have lived the last

two scores of years, have witnessed greater advancement in the science

and art of medicine than all the Methuselahs of the past combined.

It is not my purpose to laud this faculty or to proclaim its policy, but

results have demonstrated the effect of honest and earnest endeavor

^Address before the graduating class of the Detroit College of Medicine,
Thursday evening, May 17, 1906.

242 ORIGINAL ARTICLES.

ev^n when unaided. Year by year saw added responsibilities put upon
the college if she would do her full duty to those confiding in her nur-
ture, and maintain a high standing among her sister institutions. These
she promptly and cheerfully assumed by from time to time lengthening
the course of study and enlarging its scope, by erecting larger build-
ings, installing and thoroughly equipping new laboratories, and withal
voluntarily raising the standard of admission even though it materially
cut down the income. All this has been accomplished without state,
denominational, or other outside help, without any adequate financial
remuneration or return for the energy expended, and often at a pecuni-
ary loss to those engaged in the work. You may ask then the reason
or need for all this labor and sacrifice. For answer I would again
point to the results obtained, the charity bestowed, for in truth it is the
benevolence of the work that made it live and prosper.

We have gathered here tonight, in keeping with a custom of our
own, for the twofold purpose of recognizing publicly and authorita-
tively the completion of required medical study, and of speaking and
responding for the last time as faculty and students. You, members
of the graduating class, have for the past four years cast your lot with
us. Whether or no you thoughtlessly at first chose your Alma Mater
we do not know ; but you knew at least that this college was particular
as to who and what you were. Now that you have remained with us
through to the end, and inasmuch as you are the sons not of Michigan
alone but of at least eight different states, we take it that your residence
here has been worth while.

As the mother-bird makes a nest wherein to rear her young, and as
she nurtures and protects them through the days of growth, then, when
they shall have attained due strength, pushes them from the nest to
try their wings in flight, now guiding and now supporting them, so
your Alma Mater, after thorough education and trial of your strength,
proud of your attainments, opens again her doors and leads you forth
to do your part in the world's work. Life is longer than a generation ;
duty is for everyone ; you have been drafted today.

Before dissolving the relations of the past four }-ears it becomes
us, who have been in the larger school of experience, to give you form-
ally a few words of counsel on matters not included in the schedule of
instruction. In the first place let me warn you not to be deceived by
present appearances. As at your christening and on your wedding day,
so now you are the cynosure of all eyes. You have just completed a
long, difficult, and meritorious course of study and are about to be
crowned with the laurel wreath of victory. But, unlike the victor in
the games of Apollo, your real work is not done. You are merely
prepared to take it up. In the school of instruction you have been fos-
tered, excused, and protected. In the school of experience, of which
Father Time is president, you will have to be solicitous, self-reliant,
and courageous. Work is the law of our being. That law has greater

DISCOURSE TO EMBARKING PHYSICIANS. 243

significance for you today than ever before. With your increased
abilities and higher aspirations difficulties will be greater rather than
less. You will have opportunities galore but you will also find as many
others beside you seeking to take advantage of them. The question for
you then is how to succeed. It is not expected of me as the spokesman
of the faculty, nor is it fitting on this occasion to descant on character
as a text, but you should ever bear in mind that high ideals are essential
to great success. If you were to ask me to state in a word how to attain
success I would answer, deserve it.

The first practical question that will come up in your minds will be
where to locate? I know very well that advice on this point is seldom
heeded. Everyone likes to find his own niche if possible and is willing
to follow advice only in case it coincides with his own wishes. One
injunction above all others on this subject, however, you should be
given. Do not buy out another doctor's practice. There may be good
reasons for selling and the location may be desirable, but the holding
of the good will and support of another doctor's patients is very differ-
ent from purchasing the good will of the doctor himself. Only recently
a letter was received from a physician in the State of Washington, who
asked only fifteen thousand dollars for his practice in a town of two
thousand.

Another matter upon which it is customary to give advice to young
physicians is that of marriage. Seven years ago we heard a member of
this faculty — strange to say, still a bachelor — ^in speaking from this
platform, declare that he doubted the patriotism of a man who does not
marry. I have seen many classes go out from this institution but I
have never seen one whole class depart in single blessedness. This
class has not been rigidly polled, but I have been told that there are at
least sixteen benedicts in it already, and another can scarcely wait until
tomorrow to sing like a lark the bliss of married life. From my own
observation I believe that most men need no encouragement to marry.
They might, however, well take advice in regard to the choice of a
wife. Burns is credited with having divided the qualities of a good
wife into ten parts. Four of these he gave to good temper, two to good
sense, one to wit, one to beauty — such as a sweet face, eloquent eyes,
a fine person, a graceful carriage ; and the other two parts he divided
among the other qualities belonging to or attending on a wife — such as
fortune, connections, education (that is of a higher standard than ordi-
nary), family blood, et cetera; but he said : "Divide those two degrees
as you please, only remember that all these minor proportions must be
expressed by fractions, for there is not any one of them that is entitled
to the dignity of an integer."

When you shall have located you will do well to ally yourselves
with the local fraternity by joining the county and state medical soci-
eties and attending their meetings. By so doing you will acquire some
of your best friends, aid your establishment in the community, and

244 ORIGINAL ARTICLES.

obtain the benefit of postgraduate study at home. It goes without say-
ing that an active participation in the affairs of these organizations will
secure the best results.

Your relations with your fellow-practitioners should be ef the most
cordial character. For your own sake do not be a "knocker." A doc-
tor in an inland town recently told me of a fellow-practitioner with
whom no other doctor in the vicinity would consult because of his
unfair dealings. His aim seemed to be to disparage the abilities and
methods of others. To my knowledge that particular "knocker" has
already moved twice.

"The Principles of Medical Ethics," recently placed in your hands
through the courtesy of the American Medical Association, indicate the
correct line of conduct toward patients, fellow-practitioners, and the
community, and though they are intended to be advisory merely they
are well deserving of thoughtful study and adoption.

It is not supposed that any of you have taken up the profession of
medicine as a money-making business. If so, there are more than nine
chances in ten that you will be disappointed. You should, and doubtless
will, obtain a competent living, and earn much more for which you will
receive your reward in the hereafter. You will sometimes have to be
satisfied without even the gratitude of patients to whom you shall have
rendered valuable services. It will be gratifying to find, however, that
most people expect to pay for value received. Follow the Golden Rule
in your conduct and you will usually be treated in like manner. Ek)
not be cast down if you should learn that your patients have consulted
a rival. It may be that even at that moment some of your rival's
patients are on their way to consult you. Be just to yourself. You
need not expect to satisfy everybody or anybody always. Your individ-
uality, if you have any, will not make it possible. Be dignified. Place
a proper estimate upon your own services and do not underrate them
by beating down your colleague's fees. Remember that you can never
build yourself up on a substantial foundation by in any manner under-
mining any other person, be he physician or layman.

There has sprung up during the past few years the practice of
"dividing fees." It is essentially a brokerage business, and is on a
par with the practices of "runners" in "bath cities." Inasmuch as the
entire transaction is done without the knowledge of and nevertheless
at the expense of the patient, it becomes unscrupulous and ends in a
skin game. The physician, who treats or examines and refers a patient
to a specialist, should collect, for services rendered, from the patient
himself and not from the consultant, and the specialist should not
exhaust the patient's ability to pay the first physician's bill. This
arrangement is natural, honorable, and equitable to all concerned, while
graft-seeking and bribe-giving easily descend to a traffic in human lives.

Lastly do not be a curiosity shop. Be alive to and interested in
everything that attracts most men. Be public spirited. Be a politician

LESSONS IN LONGEVITY. 245

if duty requires, but remember that a busy, successful physician and a
politician are never one and the same person. Your profession must
be your first and chief occupation — ^your true vocation. That does not
mean, however, that you should not have an avocation as well. Take
time to live. You owe it to yourself, to your family, friends, everybody.
The time has now come to say to you as students. Farewell, but by
your leave I will say instead, Welcome, members of a noble profession.
We wish you Godspeed.

MEMOIRS.

LESSONS IN LONGEVITY.*

By JOHN S. CAULKINS, M. D., Thornville, Michigan.
FIRST PAPER.

Many physicians know that the writer of this paper is very old, and
some know that his era dates back to 1822, the long stretch of eighty-
three years lying behind him. From the knowledge of this fact an
expectation has arisen that he ought to have something to say relative
to old age which might have a modicum of value. This feeling is
doubtless stimulated by the observation of another fact, which contem-
plates the retention of a degree of vigor and activity (physically at
least) perhaps somewhat greater than usually falls to the lot of those
who reach his advanced age. Therefore, in compliance with repeated
requests this paper has been prepared and is submitted for what it is
worth. What is to be said on the subject will be formulated under
these two heads :

(i) Is it desirable to attain the age of eighty-three years?

(2) If so, how is that objective point to be reached?

For lack of time only the first question will be considered today,
the second being reserved for subsequent papers.

Is it desirable to attain the age of eighty-three years? This ques-
tion is to be considered from two points of view — ^the personal and the
sociological, and viewed from either the answer depends. It is the
surroundings that must determine. Aside from the instinctive clinging
to life, which is natural to most of the human race, a rational and dis-
passionate view would lead one to answer this question in the negative,
and to add that there cannot be much left to tie an octogenarian to
earth. Youthful friends and associates have one by one gone and left
him, and he is "a pilgrim and a stranger." Things in this world being
so unevenly divided there is for the most want and poverty to be
endured, while infirmities of age being many, there is pain to suffer.
All this for the very old makes life not worth living. There are, of
course, exceptions to this. Where a temperate and well-spent youth

*A paper read before the Lapeer County (Michigan) Medical Society by its
oldest member.

246 ORIGINAL ARTICLES.

and middle age have stored up a reserve of health and vigor ; where
there yet remains a good degree of interest in things and events, and
there is money enough to supply all reasonable wants, life may be quite
enjoyable long after reaching the age at which, according to Osier's
new gospel, persons should be chloroformed.'*' It is an old proverb that
a man is no older than he feels. It is not the lapse of years but the
breakdown they bring that counts.

Examined from the other point of view, that of the community in
which the old man lives, it will still be seen that the answer depends.
If he can yet perform some useful work better than younger men he
will of course be tolerated, and even if his usefulness is over, if he has
money enough to pay his way he will be accorded tolerance ; but if he
is helpless, and poor, too, very little interest is manifested towards him,
however useful he may have been in his youth and manhood. Society
is as ruthless in this humanitarian age regarding the treatment of the
infirm old as it was in the stone age, when the custom prevailed of
killing such as could no longer take care of themselves. That indeed
looks cruel to us and we are apt to shudder at such barbarity, but a little
reflection will demonstrate that it was not invariably, and probably not
generally, barbarity which caused the act, but that a stem necessity of
the savage state compelled it, and sometimes made the apparently mer-
ciless procedure one of the greatest humanity possible. Suppose a case
where winter was at hand and provisions were scarce. The tribe must
migrate and find some place where hunting and fishing are better, and
the long journey must be made on foot. What must be done with the
lame, sick, and bedridden? The choice lies between leaving them to
die of hunger or to the still more horrible fate of being eaten alive by
wolves, or giving them the "happy dispatch." Certainly humanity dic-
tates the latter, and the victim himself having always anticipated the
inevitable end, unless war or accident intervened, and having served
his father the same way, would invoke his barbarian fortitude and
willingly submit to his fate.

Methods vary but results are about the same in every age. The
primitive method has much to recommend it. It is quick and easy. One
bounce on the head with a big stick in muscular hands,' one sharp, short
pain, one quiver and the old grandfather was off to the happy hunting
grounds, and the bread he would have eaten helps to feed the grand-
children through the winter.

We no longer use the club or any similar instrument to "shuffle
off" incapables, but we confine them in houses, generally unsanitary,
where the minimum amount of care and comfort is found and let them

'^This allusion to Osier is, like what he himself said in his valedictory at
Johns Hopkins, merely jocular. Perhaps no little, casual utterance ever made
such a commotion in a community as that. Every magazine and paper has had
its fling at it and its author, and most of them have made the mistake of taking
him seriously. That he was very wrong in the assertion will be shown further
on, some good having been done, with the most far>reaching good results, after
seventy and eighty were past

LESSONS IN LONGEVITY. 247

live as long as they can. Very little interest is felt in them and they
are not missed when dead. In our present imperfect state of human
society we cannot look for anything else. It is the law of Nature that
whatever is born must grow old and die, and the law is necessary and
beneficent, for otherwise the earth would become overcrowded and
unable to support its inhabitants. The unavoidable conclusion follows
that the old must give place to the young, since the natural rights of
every human being are equal. The old have had their turn, and it is
proper that they should not stand in the way of those who come after
them. Since this is so, it is not strange that many who have the care
of the very old grow indifferent to their want of comfort, and look at
them as a burden of which they would gladly be rid. This indifference
is not unfrequently felt by its victims so acutely that a resort to suicide
is the only way to escape from the intolerable condition.

Concluding this part of our discussion we repeat what was said at
the outset, that the answer to the query, "Is it desirable to live eighty-
three years?" is dependent on the surroundings of each individual,
adding the remark that probably with the most of those who reach that
advanced age it is wholly undesirable.

We will now discontinue the discussion in this pessimistic way, and
from a wider point of view look at it as applicable to the whole human
family, and restate the question like this : "Is it desirable that the aver-
age duration of human life on our planet should be made longer than
it now is ?" Stated this way the unanimous answer will be in the affirm-
ative, and we may add that it is not only desirable but necessary and
indispensable if the world is ever to be rid of the evils by which it at
present is infested. Ignorance is the evil and the mother of evils. Her
children are poverty, crime,' war, and pestilence, and there is mutual
reaction between them tending to enlarge the circle of malign influence
of which each is the center. There is a remedy for every evil caused by
ignorance. This none can be stupid or inconsequent 'enough to deny.
The remedy is the discovery of scientific truth and its application to the
affairs of men : the discovery of the true laws of Nature and obedience
to them, whether physical, mental or moral. Truth is in her well and
must be hunted for and drawn from its recesses. This needs time,
which we do not have in our short term of life — our three score years
and ten. The years for doing good work are too few. We must stop
and die before our plans are half executed. The time for study being
so limited progress is slow. Some say that nothing of real value is
performed after sixty is reached. There is reason to believe this limit
an underestimate, but we must admit that the time is very short at the
best. There is a great loss where one man has to take up the unfinished
work of another. He cannot begin right where the other left off, but
must go through all the preliminary work that his predecessor has
already mastered. It is a great waste and, besides, not very safe.
Youth is available in adventuring into new paths and noting new facts,

£i8 ORIGINAL ARTICLES.

but is too volatile, self-conceited, quarrelsome and vindictive to do
anything but one-sided work. The effervescence and querulousness of
youth must subside and be replaced by the calm modesty of the sage
and philosopher who has burned the midnight oil in his search for the
truth till it stands irrefutable and apparent to every inquirer.

Suppose the short working period doubled. It would far more than
double our product. Instead of our present slow progress the potential
of human endeavor would increase in geometrical proportion. When
the time arrives that the octogenarian, instead of being counted as at
present, hardly belonging to the living, but looked askance at as merely
a wreck or derelict on the ocean of time, will be, as the Germans say,
in his best years, then this earth will be a good place in which to live out
a long lite. The remedies for poverty and crime will be found, wars
will cease and be replaced by arbitration, and the cause of every disease
will be hunted down and stamped out, old age included, which, accord-
ing to the discoveries of Metschnikoff is, like the most of human ills,
a microbic disease and can no doubt like the rest be avoided.

It has been truly said that no chain is stronger than its weakest
link. But why have a weak link in the chain. Let the smith look to his
work and make every link out of the same flawless iron and every weld
perfect and then there would be no break anywhere, the chain would
hold all the team could draw, and all would wear out together, like the
''one boss shay." Lives are the links in the chain of human existence,
and although most of these links are very weak there are now and then
notable exceptions that have grown up with sufficient cellular stability
to outlast three or four ordinary lives. These exceptional cases have
of course reasons and causes that account for them since every result
is the effect of a cause, and the uniformity of Nature's laws teaches us
that like causes produce like effects. What man has done man may do.
It is the business of the philanthropist and philosopher to study and
learn what these causes are as fast as possible and teach them to the
rest of mankind. Some work has already been done along this line,
more is being done, and much remains to be done.

It is to be expected that here the pessimist will step forward to urge
that it is Chimerical to believe that lengthening the span of human life
can have any good influence toward lessening the sum of our ills but
might instead prove a damage by lengthening the term of the undesir-
able classes, the criminals, and weaklings, equally with the best. This
is easily answered. It is equivalent to asserting that there is no human
progress, and we know there is. The race has always followed the
best light it had, otherwise we would still be wandering savages like our
ancestors of the stond age. Poverty is the prolific mother of most
crimes and they will die with their mother, and as for the weaklings
who now mostly die in infancy, if they live to grow up, it will not be to
propagate their own degeneracy. Among the discoveries of the future
there will be one for the humane, easy, painless and complete steriliza-

LESSONS IN LONGEVITY. 249

tion of such as are not fit to propogate the species. Why should not
man be improved by applying to him the methods that govern improve-
ment in other animals ? It would puzzle anyone to say why not. Suppose
this work done and the improvement of the animal Man placed on a
sound and strictly scientific basis, what would the result show his nat-
ural term of life to be ? The other animals have a limit at which, if
they escape disease and violence, they die from sheer old age, their
stock of vitality being exhausted. It is not likely that the genus homo
is an exception to the rule. Several students of nature have treated this
subject, basing their conclusions on comparisons between man and other
animals relative to the ratio between the whole length of life and the
period of certain stages of it, such as gestation, dentition, lactation, and
growth, the last attracting the most attention. Comaro, in Italy,
Buffon, the naturalist of France, and Hufeland of Germany have writ-
ten on this subject, the latter the most elaborately. His book, "Macro-
biotik," has been translated into all the European languages and into
several Asiatic. Of these three, Comaro only contends for a hundred
years, Buffon for one hundred and forty, but Hufeland says, page 149
(Erasmus Wilson's edition), "We may with the greatest probability
assert, that the organization and vital power of man are able to support
a duration and activity of two hundred years." He goes on to say,
"This assertion acquires some weight by our finding that it agrees with
the proportion between the time of growth and the duration of life.
One may lay it down as a rule that an animal lives eight times as long
as it grows. Now, man in his natural state, where the period of matur-
ity is not hastened by art, requires full twenty-five years to attain his
complete growth and conformation, and this proportion will give him
an absolute age of two hundred years." Chapter V of his book (first
part) is devoted to instances of long life, considered by countries and
professions. He says the medical makes the poorest showing among
the professions. In a table which he gives of the ages of distinguished
physicians there is only one above the one hundred mark. It is the
name of our great founder, Hippocrates. He says, page 25, "Mortality
is greater among practical physicians than perhaps among men of any
other profession. * * * The greatest mortality prevails during
the first ten years of practice. * * * A physician who has luckily
passed his time of probation may become an old man."

This paper is quite long enough for the first of the series, and the
discussion will be dropped now with the understanding that it shall
be resumed later. I may as well admit that besides willingness to
please, by complying with your repeated requests for the paper, there
was a little "motif" of my own hidden behind its preparation, and
here it is. You remember Robbie Burns' lines:

"O wad some power the giftie gie us,
To see oursel as ithers see us.
It wad frae mony a blunder free us
And foolish notion."

250 ORIGINAL ARTICLES.

It goes without saying that the old man is not in so good condition
to sec "himsel" as "ithers" see him as a young man would be, and as he
comes nearer to the jumping-oflF place he gets less and less fit for the
effort. It is not prudent to skate too far out on the ice of which one
does not know the strength and thickness: better stop and see if it is
safe for fear one will come to grief in the cold water. There is a
stopping place somewhere just ahead and sometime everyone will find
it, and how is the old man to know, since he cannot see for himself,
when he has reached the spot. Evidently there is no way but to make
a little trial and watch the result. This paper is an effort in that direc-
tion. If an unfavora))le impression has been created, serve the writer
as the old Romans did their wounded and inefficient gladiators, — ^tum
down your thumbs and put him out of his misery.

[to BB COMTINVBD.]

EXPERIENCE WITH STATIC ELECTRICITY.*
By NEIL A. GATES. M. D., Dexter, Michigan.

It is not my intention to delve into ancient history and dilate on the
antiquity of static electricity as a factor in the treatment of disease con-
ditions, but simply to report a few cases from an experience extending
over the past seven years, and endeavor to demonstrate that this thera-
peutic agent is not to be regarded with indifference by the general practi-
tioner. It may not, however, be amiss to say that from the year 1750,
when it was first introduced into medicine, it has made rapid strides in
advancement, until in the year 1905, when by being the best electrical
means of exciting a vacuum tube for jr-ray work, it has become not an
expensive luxury but an absolute necessity, and even the humblest of
practitioners cannot afford to be without its valuable aid. It is a means
which we should all employ rather than relinquish to the practice of
specialists. The startling results achieved with electricity in relieving
aches and pains and in the treatment of a large proportion of nerv-
ous ailments due to our strenuous and unnatural mode of life, render
the static machine an important acquisition to the armamentarium of the
successful physician.

In this paper, owing to lack of time, I will confine my remarks to
the treatment of disease conditions by static electricity alone, although
I am well aware that since its entrance into the interesting and wonder-
ful field of jr-ray work its past usefulness seems to have been over-
shadowed and left in the hands of a few. To be successful, there are
some duties we owe to our machine and many points we must always
bear in mind.

We must have a reliable machine, large enough to obtain good
results. A great percentage of those who have tried static electricity
and reaped disappointment must ascribe failure to small and cheap
machines. There are many firms now making machines which,

*Read before the Washtenaw County (Ann Arbor) Medical Society.

STATIC ELECTRICITY. 261

although they present a fine appearance in the office, are practically
worthless, for, by reason of cheap construction, they will not work in
all conditions of weather and soon wear out even under the most favor-
able treatment. I can readily see how a brother practitioner, having
obtained one of these machines, soon becomes discouraged and con-
vinced that the usefulness of static electricity is confined to the good
impression a patient receives by being treated with so large and for-
midable an apparatus. That this is erroneous, and that static electricity
penetrates to the deeper organs and cures, not by hypnotizing, but by
relieving inflammatory conditions, I shall endeavor to prove.

To get the best results one must have a suitable room and sur-
roundings, generally the more room around the platform the better,
and, most essential of all, two good ground wires. With a modem
machine, given a little attention each day, one can use it with the best
of results every day in the year.

Physicians must study patients. We all know that electricity of any
kind is very disagreeable to some patients, but by carefully giving a
short treatment with static insulation, and then following with the
static breeze, demonstrating that the patient is not to be subjected to
sudden shocks, the benefit derived will soon convince each that he is
on the road to health, and the operator will be surprised to learn that
these timid patients soon withstand a long spark and even insist upon
having it, the relief from pain being so great that any inconvenience
for the moment is soon forgotten. One will learn that a patient will
readily take treatment when he finds that it is unnecessary to remove
any part of his clothing. Think of the saving of time to a busy prac-
titioner when a patient comes from the street and without delay steps
upon the platform, receives treatment and departs without removing
and replacing wearing apparel.

One must also lake into consideration the material of the patient's
clothing, whether woolen or cotton, and remember where pins and
steels are likely to be concealed. In giving treatments one must always
exercise the greatest care not to unnecessarily alarm the patient by
accidentally touching him or placing him too near objects in the room.
This is especially true if the patient is dressed with woolen clothes.

A great many operators recognize no difference between the posi-
tive and negative poles of the machine. This is a great mistake, for
the positive pole acts as a stimulant and the negative as a sedative.
This refers to general electrification only, for in the employment of
the breeze and spark the reverse is true. A physician can readily see
that he must understand the condition of the patient as well as the
machine, and I will add that the better one attends to these details the
better will be the result.

Without consuming more time in explaining the diflferent forms
of treatment, I will, by reporting the history of a few selected cases,
endeavor to show the various forms of treatment I adopt in different

252 ORIGINAL ARTICLES.

cases and the startling results I obtain, which, I am sure, all practi-
tioners will agree could not be attained with drugs.

Case I. — A tailor, age thirty-six. From the effects of overwork
patient was nervous, run down, and troubled with insomnia, having
severe headaches and nausea. One night after a hard day's work over
a gas-heated iron, the fumes from which were overpowering, this man
closed his shop, being unable to work longer. He came into my office
and after a careful examination I placed him on the platform con-
nected to the negative pole of the machine, grounded the positive pole,
and to this attached a brass-pointed electrode. I then started the
machine and slowly moved the electrode (keeping it about six inches
from patient) up and down his back, over his head, and finally down
in front of him, letting it come to a stop in such a manner that I could
get a strong breeze over the region of his stomach. I continued this
treatment ten minutes. The patient then left the office, opened his
shop, and worked three more hours without any discomfort. Pursuing-
this case I gave patient daily treatments of ten minutes each for two
weeks, when they were discontinued, being firmly convinced that he
had entirely recovered, and time proved the correctness of this convic-
tion.

Case IL — A merchant came to me complaining of insomnia.
Patient had been subjected to considerable mental strain for the past
six weeks owing to business difficulties. The effect was a nervous
affliction manifesting itself in severe insomnia. A brother practitioner
had advised a vacation with a trip to the seashore, but this was impos-
sibe for many reasons. Physical examination disclosed nothing but
extreme emaciation and weakness. I advised a system of potential
alternation treatments, which allowed the patient to continue the
administration of business affairs, an absolute necessity. Patient came
to my office evenings after closing his store. I placed him on the plat-
form and grounded the negative pole which was attached to the head
crown electrode. I connected the positive pole of the machine to the
platform and also attached it to a copper plate placed under the patient's
feet. Before administering this treatment I either had the patient
remove his shoes, or placed several thicknesses of paper between elec-
trodes and soles of shoes as bare shoes coming in contact with elec-
trodes will cause an unpleasant sensation to the feet, annoy the patient,
and counteract the good effect of the treatment. Next I took a long
chain connected to a separate ground wire and attached it to a brass
ball electrode held by a holder. Then I placed the brass ball from one
to three inches (as this case required) from the electrode connecting
the positive pole to the platform, and started the machine, the spark
gape between electrode and brass ball being guaged to suit the patient.
I continued the treatment for ten minutes. The patient went home and
had a good night's rest, sleeping, as he said, more profoundly than he
had in a month. Patient took similar treatments nightly for three

STATIC ELECTRICITY. 263

weeks, when all symptoms disappeared, and he had gained four pounds
in weight, felt free from worry, and was entirely well. I will add that
I have used this form of treatment in many cases and consider it
the best tonic sedative. I have often had patients enter the condition
of sleep during the treatment, and have never experienced failure to
cure insomnia.

Case III. — A housewife, age thirty, mother of four children, had
slight laceration of cervix and perineum. She complained of dragging
pain in pelvis, backache, headache, and nervousness, the latter symp-
tom being so pronounced that she feared loss of mind. I advised oper-
ation for repair of cervix and perineum, which was done, but without
improvement of condition. Patient complained more after the good
effects of a much-needed rest, which the operation necessitated, wore
off. I then employed the static breeze as in Case I, limiting the breeze
more especially to pelvis, back, and head. Three weeks' treatment
effected a cure, and now, after two years, there is no return of the
symptoms.

Case IV, — A lumberman, fifty years old. He suffered occasional
attacks of lumbago for eight years. When I was called, patient had
been confined to bed two weeks, being unable to turn over without
assistance. His doctor had been administering salicylate of soda inter-
nally, with counterirritants to back, and relieving pain with daily
hypodermics of morphin. Much to the disbelief of patient's friends
and himself I informed him that I could do nothing further for him at
his home, but that if he could get to my office I would cure him in two
minutes. Although the patient could not believe it possible, after strong
urging, I induced him to consent to the transfer. A great deal of per-
suasion was necessary to influence a man in his condition to drive one
mile, but after placing a cot in a spring wagon and conveying the patient
thereto, the start was finally made. It was in the fall of the year, when
the roads were rough, and after going a few rods patient insisted on
getting out of the vehicle, and, with the help of crutches and my assist-
ance, walked the rest of "the journey. After a short rest I laboriously
placed him on the platform of the machine and administered a six-inch
positive spark, obtained by connecting the platform with the negative
pole, grounding the positive pole, the electrode being connected to the
ground wire. I administered the sparks with the patient standing, as
it was impossible for him to sit. In about two minutes I discontinued
the current and requested him to step off the platform. Much to his
surprise and gratification he did so, and found that he could bend
forward and place his hands upon the floor without any discomfort.
After the patient had walked around a bit I again administered mild
sparks for ten minutes, and I can truthfully say that during the last
four years he has not had a symptom of lumbago. This may seem an
exaggerated case but I can give assurance that it is not, and anybody

254 ORIGINAL ARTICLES.

accustomed to the moderate use of static electricity has had many
similar experiences.

It is needless to say that the patients this particular case has brought
me would pay for a great many static machines. I have treated many
cases of lumbago and other forms of muscular rheumatism, and where
I can use a six-inch spark I never fail to give instant relief. In cases
where the patient will not tolerate the spark the positive breeze will
surely effect a cure, although longer time will be required.

Case V. — A furniture dealer, age forty-two. After sustaining a
wrench of the shoulder, followed by rheumatic pains, this man con-
sulted me regarding a partial paralysis of his right arm. On examina-
tion I found almost a complete atrophy of the trapezius, deltoid and
infraspinatus muscles. I connected the patient to the machine in order
to obtain the induced static current, using the smallest Leyden jar I
had. Patient was requested to hold one electrode in his left hand while
the other was placed to his shoulder outside clothing. I then started
the machine slowly, and for five minutes caused feeble contraction and
relaxation of these muscles; then for another five minutes turned the
machine rapidly, using the current as a massage. This treatment was
continued for four weeks, resulting in complete cure of the paralysis
and restoration of muscle symmetry.

Case VI, — An unmarried woman came to me suffering from amen-
orrhea and accompanying symptoms which I diagnosed as chlorosis. I
gave the patient daily treatments of positive insulation continued for
ten minutes and accompanied by a negative breeze to the pelvis. In
three weeks the patient was discharged well.

Case VII. — A married woman consulted me for a badly sprained
wrist following a fall. There was no fracture or dislocation of the
bones. I treated the wrist daily with static breeze, with the result that
swelling and soreness subsided within a week.

Case VIII. — An unmarried woman sought relief from a distressing
acne indurata. I employed the positive breeze on her face, using a
wooden electrode. Three weeks sui&ced to effect a cure.

In selecting these cases for report I purposely picked those in which
no drugs were used. I would not say that this is wise in every instance,
for I think it better in many cases to employ both. The results show,
however, that a great deal can be accomplished with static electricity
alone. I do not wish to impart the' impression that static electricity is
a cure-all, for it is not, but it can be employed, with safety, in every
case. Nothing will relieve the pains of neuritis, nervous headache,
and the vomiting of pregnancy so quickly as will static electricity.

In closing I will add the assurance that from my own experience,
after a hard day's work, nothing is more refreshing and invigorating
than ten minutes application of the static breeze. Try it.

CLINICAL SOCIETY 265

TRANSACTIONS.

CLINICAL SOCIETY OP THE UNIVERSITY OP MICHIQAN.

STATED MEETING, JANUARY 15, 1906.

The President, WILLIAM K. LYMAN, M. D., in the Chair.

Reported by DAVID M. KANE, M. D., Secretary.^

REPORT OF CASES.

ADENOIDS,

Doctor William R. Lyman : I do not intend to discuss the sub-
ject of adenoids fully, but rather to report some observations based
upon a study of the records of the Otolaryngologic clinic at the Uni-
versity Hospital for the year 1905 ; to compare them briefly with our
accepted opinions; to call attention to the frequency with which this
disease is accompanied by serious complications and to emphasize the
importance of early treatment.

During the year 1905 there were examined one hundred and forty-
five cases of adenoids, of which number seventy-nine also had chronic
hypertrophy of the faucial tonsils; in fact, in many cases it was the
tonsilar condition which brought the patient to the clinic for relief.
Many of the patients were college students, which fact is of importance
in the interpretation of data to be brought forward later. As to sex
there were ninety males and fifty-five females. The preponderance of
males as compared with other statistics is explainable by the fact that
this clinic draws largely from the student body for its material. For
purposes of convenience the following tabulation sets forth the number
of patients per semidecade :

From 1-5 years old 9 From 5-10 years old 39

From 10-15 years old 31 From 15-20 years old 21

From 20-25 years old 31 From 25-30 years old 8

Over 30 years old 6

One is at once struck by the small number of cases found in the first
semidecade of life, during which period we are informed the greatest
number of patients present themselves to our observation. The great-
est number of any single semidecade was that between the ages of five
and ten. Fully thirty-six per cent of our cases occurred between the
ages of fifteen and twenty-five. One case was that of an adult fifty-
seven years old. These figures are quite at variance with those ordi-
narily set forth, but the fact admits of ready explanation. The pres-
ence of nasopharyngeal abnormalities is often overlooked by the
parents. The significance of adenoids in children is not widely or fully
appreciated and a large per cent of the patients of this clinic were Uni-
versity students, which latter fact alone accounts for the variation.

Of importance is the time of year during which the greatest number
of patients presented themselves for treatment. The records for April

256 ORIGINAL ARTICLES.

and May show an enrollment of thirty-five cases, which suggest the
relationship of adenoids to the nasopharyngeal disturbances so
frequent in early spring. The patients in general complained of
the classical symptoms of the condition— difficult nasal re^iration,
mouth-breathing with its characteristic facial expression, and, to
quote Doctor Schadle, "The open mouth, the pinched nose, the
drawn down inner canthi, elevated eyebrows, corrugated skin of the
forehead, the distorted chest, the altered voice, the apparent defective
development — ^both mental and physical." There may be added : pro-
truding upper teeth, and high palatal arch; repeated attacks of sore
throat, which is generally due to the associated tonsilar hypertrophy ;
a fullness and the sensation described as something dropping in the
back of the throat ; a seromucoid discharge from the nostrils ; the state-
ment of the parent that the child is apparently aflFected with a continu-
ous cold in the head ; a voice thick aq^ without resonance, such letters
as m and n not being pronounceable ; and, frequently, palpability of the
submaxillary and cervical lymph glands.

Adenoids are characterized by the occurrence of complications
directly due to the condition. Among those most prominently met
were the following : Deafness of varying degree in sixty-five patients,
some complaining of only slight stuffiness of the ears and occasional
tennitus, both of which conditions were more marked when the patient
had a cold. Many could hear the whispered voice, if at all, only a
fraction of the normal distance, which is twenty-one feet. There were
about thirty patients who had discharging ears at the time of examina-
tion, and many more cases in which the examination showed evidences
of previous suppuration. The presence of adenoids was a marked
factor in the susceptibility to the acute infectious disease, particularly
measles, scarlet fever, and whooping-cough ; repeated attacks of tonsil-
litis, pharyngitis, and acute rhinitis, the patients taking cold at the least
exposure ; a constant dry, hacking cough ; gastrointestinal disturbances,
manifested by a rapacious appetite and alternating constipation and
diarrhea; retarded mental development, many of the children being
several grades less advanced in school than normal children of similar
ages; while several cases showed defective development of the chest,
resulting in pigeon-breast.

The treatment has been complete removal of the growth, this being
done under primary ether anesthesia with the patient in the sitting
position. The instruments used were the adenoid forceps, Mthen the
tissue was abundant, followed by the Beckmann curet, and all small
portions remaining were removed with the finger.

The results have been without exception favorable. There has been
no case of hemorrhage. Those cases accompanied by ear complications
have been very satisfactory both as to the improvement in hearing and
the cessation of the discharge. The improvement in the general con-
dition was very noticable, and this was especially true in the young
patients.

ANN ARBOR MEDICAL CLUB. 267

Among the reasons for the removal of adenoid vegetations may be
mentioned : The prevention of pathological conditions of the ears and
the beneficial effect upon the ear complications; the establishment of
free nasal respiration, thus doing away with mouth-breathing and its
attendant disadvantages; the marked and rapid improvement in the
patient's general health. The last two conditions were much more
striking in the young patients. The removal of a constant source of
infection, statistics showing that one case in five have tubercle bacilli
either in the substance of the growth or upon its surface, and, as already
mentioned, the presence of adenoids increases the susceptibility of the
patients to the acute exanthemata.

The dangers of the operation, if correctly performed, are very slight
and the beneficial results as marked as those derived from any operation.

ANN ARBOR MEDICAL CLUB.

STATED MEETING, APRIL i8, 1906.

The President, JOHN A. WESSINGER, M. D., in the Chair.

Reported by JOHN WILLIAM KEATING, M. D., Secretary.

REPORTS OF CASES.

RETENTION OF URINE.

Doctor Cyrenus G. Darling : I wish to report two cases to show
some methods of treating retention of urine. A man, seventy-five years
old, had been using a catheter for five years because of enlarged prostate
and cystitis. One day he was unable to pass the soft rubber catheter
that he was accustomed to employ, and attempted to insert an old one
which had been about the house for some time, because it was smaller.
The tip had already been broken oflF. He not only failed in the attempt
at satisfactory insertion but when he tried to withdraw the instrument it
broke, leaving a piece of unknown length in the bladder. To still further
complicate matters he threw the withdrawn fragment into the fire. He
then called his physician who secured three fragments of catheter, prob-
ably all that had not been previously removed ; still the physician was not
able to gain acress to the bladder because of the injury which the patient
inflicted upon himself. I saw patient about thirty-six hours later,
when I found the bladder enormously distended because no urine had
been passed. The pulse was weak and he presented all the signs of a
septic condition. I decided to drain the bladder but patient was in no
condition to take an anesthetic. I then made a suprapubic incision
under local anesthesia (Schleich's solution). A large amount of very
offensive urine was allowed to flow slowly away, and the patient was
immediately relieved but was already so septic that he did not improve.
He became gradually weaker and died on the following day. The second
case was that of a boy eight years old who fell astride of a stick, com-
pletely severing the urethra. This was followed by infiltration of the
perineal tissues and retention of urine. The physician failed to find the

258 ORIGINAL ARTICLES.

opening of the torn urethra and reached the bladder by puncturing with
a trochar through the perineuni along the supposed line of the urethra,
and introducing a tube for the purpose of forming a new urethra. After
the tube was removed the new urethra remained for some weeks, but
gradually contracted until no urine could be passed except by drops.
Patient was brought to the University Hospital in this condition. For
immediate relief suprapubic puncture was employed. The following
day I attempted to find the end of the torn urethra by a perineal incision,
but failed. I was obliged to resort to retrograde catheterization by
incising the bladder, finding the urethral opening and introducing a
catheter into it. This was carried anteriorly until the tip could be felt in
the perineum, where the end was exposed by an incision. The other
end was treated in. the same way. Because of a large amount of cica-
tricial tissue no attempt was made to suture the ends but an English
catheter was placed in the canal and kept there for a few days until the
ends were approximately united. The wound in the bladder was closed.
The patient left the hospital with a good urethra. When the catheter
fails, retention of urine may sometimes be relieved by putting the patient
in a warm bath, by using a general anesthetic to relax spasm, or by supra-
pubic puncture or incision. These latter may frequently be employed
when a general anesthetic would not be safe. Incision should be made
when it is necessary to drain the bladder. The use of Schleich's solution
completely anesthetizes all of the tissues except the bladder wall. This
is opened with a single, rapid incision. Puncture is so easily and safely
performed that there are but few reasons why it may not be employed.
Retention must always receive prompt treatment when cystitis is present
or more serious ccmditions may follow, as in the first case reported.
Retention from rupture of the urethra is treated by early perineal
incision, with suturing of the torn ends, or holding in place by catheter
as mentioned in the second case.

AN UNCOMMON FRACTURE,

Doctor Ira D. Loree: This fracture is not uncommon from the
fact that it does not occur frequently but because it is not often diag-
nosed. In the past fracture of the carpal bones has, no doubt, many
times been overlooked, but with the great advantages offered by the
radiograph the true nature of many wrist sprains is coming to light.
This patient was sent to me by Doctor Yutzy. His accident hap-
pened while scuffling, which resulted in a fall and striking upon his
hand. Whether or not he fell upon it in a way to produce flexion or
extension he could not tell. The seat of injury was too far forward to
be a Colles' fracture, and while deformity and crepitus were absent,
there was too much pain, and swelling in the soft parts, not to interpret
a broken bone. The radiographs which I pass around readily reveal
the seat of difficulty in the os magnum and scaphoid. To properly diag-
nose this condition both wrists should be photographed, as sesamoid
bones may be mistaken for fracture.

FAT INDIGESTION IN INFANTS. 259

ORIGINAL ABSTRACTS.

SURGERY.

By FRANK BANGHART WALKER, Ph. B., M. D.. Detroit. Michigan.
movassoK of sukgut amo opbkativb sukgbrt in tub dbtkoit potTGKADUATS SCHOOL or mboicimb:

ADJUNCT FftOPBSSOB OF OPBBATIVB SOBGBBT IK THB DBTBOIT COC.LBCB OF MBOICINB.

AND

CYRENUS GARRITT DARLING, M. D., Ann Arbor, Michigan.

CUMICAL PBOFBSSOB OF SVKGBBT IM THB UMIVBBSITT OF MICHIOAM.

MORTALITY AFTER PROSTATECTOMY.
In Jcma, Volume XLVI, Number XIX, Tenney and Chase give
some interesting observations on the results of prostatectomy. Age of
itself, they state, is no argument against the operation, but their figures
show better than any amount of argument the desirability of early oper-
ation. The convalescence of elder patients was in marked contrast to
that of the younger patients. In studying seventy-three deaths fatal
periods were noticed. There were twenty-three deaths, or more fatali-
ties in the first forty-eight hours than in any other two days. Another
period of mortality includes the seventh, eighth and ninth days, which
showed twelve deaths. On the thirteenth and two following days there
were six deaths, and on the twentieth to twenty-second days inclusive,
there were seven deaths. Two-thirds of all the deaths came during
these fatal periods. Contrary to statements by MouUin, Richardson
and others that patients with stone in the bladder are more favorable
subjects for operation than others, their list contains one hundred seven
cases complicated by vesical calculus with a mortality of thirteen or
twelve per cent, as compared with 8.6 per cent mortality among the
cases without stone. The inferences drawn from a comparison of mor-
talities with ages were that the older men are less likely to stand the
shock and loss of blood in the operation, and that the younger men
stand the sepsis, uremic complications and confinement less well than
the elders. Believing that the result is not so much a problem of speed
or technic in the operation, they lay great stress upon the preparation
of the patient, the anesthesia, and the careful and intelligent attention
almost constantly during the first forty-eight hours, and the same sort
of attention later at frequent intervals until his convelescence is well
established. f. b. w.

PEDIATRICS.

By ARTHUR DAVID HOLMES, M. D.,C. M., Detroit, Michigan.

FAT INDIGESTION IN INFANTS.

LowENBURG {Medical Bulletin, November, 1905) says that an

excess of fat may not infrequently be a source of indigestion. Infants

thus fed vomit from half to an hour after feeding. The vomited

material has an odor of butyric acid and is sour. Diarrhea is a frequent

260 ORIGINAL ABSTRACTS.

symptom. The stools are greasy and respond to the osmic acid test
for fat, and oil globules are seen with the microscope. The fat may
appear in the stools as lumps not unlike those of casein. A progressive
loss of weight is soon or late a prominent feature. The condition is
best prevented by starting the infant on low fat percentages. The
increase should be gradual and never reach above four per cent. In
the active management of such a case a calomel purge should be admin-
istered if vomiting is a permanent feature. The fat should be at once
reduced to less than one per cent, and then only gradually and carefully
increased, stools and condition of the stomach being carefully watched.

TREATMENT OF ENURESIS.
Thursfield (British Medical Journal, April 21, 1906) says that
atropin used in the form of an extract, tincture, or as liquor atropin is
the only drug from which he has had good results in the treatment of
enuresis. He recommends ten minims of the tincture three times a day
as an initial dose, and increases the amount week by week until the
dose produces evidences of its action. It should be used over a long
period, usually from three to six months, for permanent relief. The
dose should be diminished gradually until it can be left off with safety.
He also recommends the use of potassium citrate in conjunction with
belladonna in the majority of cases, and in some cases where hyper-
acidity of the urine was the cause, he found the administration of
potassium citrate alone very efficacious. He also speaks highly of
urotropin well diluted.

TREATMENT OF CEREBROSPINAL MENINGITIS.
Osborne (New York Medical Record, February 17, 1906) says,
regarding the treatment of this affection, that it consists in diminishing
the congestion, in preventing or relieving the spinal or cerebral pres-
sure, and in combatting the acute symptoms and complications as they
arise. He says further that the administration of diphtheria antitoxin
in this affection is theoretically unsound and practically a failure. Spinal
puncture is of benefit in some instances for the relief of pressure, but
only in rare instances, he believes, is it indicated for diagnostic pur-
poses. The sore throat should be treated with antiseptic gargles and
sprays, and the conjunctivitis with solution of boric acid. If the pain
is not severe and the pulse good, bromides or chloral may be given ;
otherwise treat by wrapping the painful joints with cotton, applying
heat, giving a calomel or saline purge, and administering morphin.
The author believes that to quiet the cerebral excitement and delirium
and to intensify the action of the morphin in these cases the adminis-
tration of ergot intramuscularly or subcutaneously at six-hour intervals
gives good results. The ice-cap and the spinal ice-bag are necessary,
and if the temperature is subnormal or the surface of the body is cold,
dry hot applications are of advantage. He is convinced that ice, ergot,
and morphin will save many patients from death by this disease.

TUBERCULOUS OSTEITIS OF KNEE.

ORTHOPEDICS.

ait IRA DEAN LOa^ Iil^D., Ann Arbor, Michigan.

sum ASHITAKX IH. SypMSjMX I|t.TBB DMXTOaiTY OV mCMIGAM.

261

EARLY OPERATIVE TREATMENT OF TUBERCULOUS
OSTEITIS OF THE KNEE.

Bernard B/sblow, M. D., oi. QMffalo^ in the American Journal of
Orthopedic Surgery for Aprit 19P6. His report. Qonfioes, itself to three
cases in which the focus of disea^ had not reached the jcHnt, but wa3
confined to the end of the femur. He advisee excision of the diseased
bone, and, if there has been prolonged contraction, division of the
ham-string tendons. '

The histories of the two patieato which he presents a^re to substan-
tiate his previously reported resulte. in this tine o{ workv

The first patient was a girl, niw years old, with flexion posture of
forty-five degrees and a range of free movement of fifteen degrees.
There was. much enlargement of th^ inner condyle (Figure I) with pajja
at this point upon digital pressure. The tibia wa^ partially subluxated

First Patient — Figure I.

First Patient— Figure II.

with abduction and some rotation outward. She had passed the stage
of muscular spasm and night cry. After thoroughly cleaning out the
area of disease the cavity was swabbed with a five-per-cent formalin
solution, aft^r which the periosteum and skin were repaired. A plaster-
of- Paris splint was applied as shown (Figure II). After four weeks
the condition present was as indicated in Figure III. Figure IV shows
the amount of flexion obtained after twelve months. Genu valgum

262

ORIGINAL ABSTRACTS.

First Patient — Figure III.

First Patient — Figure IV.

First Patient -Figure V.

First Patient — Figure VI.

TUBERCULOUS OSTEITIS OF KNEE.

263

developed later as shown in Figure V. There was no return of the
tubercular process, however, and the former condition was corrected by
osteotomy, with results shown in Figure VI.

The second patient was a boy, three years of age. Disease had

Second Patient— Figure VII. Second Patient— Figure VIII.

progressed for three months when first seen. The joint had a typical
posture with its enlarged inner condyle, night cry and pain through the
day, with morning lameness. There was flexion posture of twenty
degrees with very slight free movement. Treatment was the same as

Second Patient — Figure IX.
before. It was necessary here to penetrate healthy epiphyseal tissue.
Massage and passive motion were employed after the sixth week.
Figures II and III show the joint eleven months after the operation
with posture, growth and range of motion normal.

864 ORIGINAL ABSTRACTS.

OPHTHALMOLOGY.

' By WALTER ROBERT PARKER, B. S., M. O.
rmowwMom ov onrrHAUiouwv m tub uwnMinr of michioam.

EXPERIMENTAL INVESTIGATIONS ON THE INFECTION
OF CORNEAL WOUNDS BY SALIVA.

HocTA (Kim. MonaisbL fur AugenkmOhmde, September, 1905)
has ftnmd that saliva may be brought iit omtact with corneail wounds
by means of objects contaminated with saliva, sudt as fiigers. and
handcercbiefs, or drops of saliva may come fhim the iterator's miMUli.

The writer's experiments were partly to determine (a) what organ-
isms in the saliva, when in contact with a^ newly-made corneal wound,
are most likely to produce a purulent ker^itis, and (b) what forait of
wound, exposed to the microorganisms of the saliva, is most likely to
give rise to purulent inflammation.

For his experiments rabbits, cats, and mice were used. Saliva was
obtsuned from persons of different ages and positions. The lids were
everted and the eye washed with 0.05 per cent sublimate lotion, then
witii physiologic saline solution.

A wound was made in the cornea :

(aa) Nonperf orating.

(i) An abrasion by scratching the surface of the cornea with

the point of a needle.
(2) A pocket, a wound made by a keratome between the corneal
lamellae.

(bb) Perforating wounds made by a Graefe knife.

Saliva taken from a sterile Petrie dish, by means of a sterilized
spatula, was carefully rubbed on the wound, or inserted into the pocket.
In the case of perforating wounds care was taken not to introduce the
spatula into the anterior chamber.

After twenty-four hours a cover-glass preparation and a culture
were made from the secretion of the wound. The media used were
neutral agar, glycerine agar, Loeffler's blood serum, and bouillon. All
media were placed in an oven at 35° centigrade.

Results of ninety experiments :

(a) Always negative in thirty perforating wounds.

(b) Once positive in diirty abrasions.

(c) Always positive in thirty pocket wounds. In most of these
cases there was iritis, hypopyon, marked circumcomeal injection and
conjunctivitis.

In these thirty cases pneumococci were found eleven times (thirty-six
per cent) ; streptococci seventeen times (fifty-six per cent) ; staphy-
lococci nine times (thirty per cent) ; tetragenus was also seen five times.
In six of the cases no culture was obtained.

CANCER OF THE LARYNX. 966

Infectioii of operation wounds by drops of saliva from the operator :
Hotta performed experiments similar to those of Hubener, but modi-
fied them in view of the special conditions present in eye operations.
He found that a veil of doubled muslin does not absolutely prevent the
spraying of the saliva. But he believes that in eye operations this is
certainly sufficient to prevent infection from the mouth. The possi-
bility of infection from the saliva during the operation cannot be abso-
lutely denied, yet.it must be so rare that in eye operations in general
a special measure to prevent it does not seem necessary.

LARYNGOLOGY.

By WILLIS SIDNEY ANDERSON, M. D., Detroit, Michigan.

ASSISTANT TO THB CMAIE ^F LABYNOOLOOT IN THB DBTROIT COLLBOB OF MBDICINB.

REMARKS ON THE MACROSCOPIC DIAGNOSIS AND GEN-
ERAL INDICATIONS FOR TREATMENT OF
CANCER OF THE LARYNX.

Doctor John Noland Mackenzie (Annals of Otology, Rhinology
and Laryngology, March, 1906) makes some positive statements in
regard to this much dreaded disease. He states that in the present
state of our knowledge there are three principal methods of diagnosis
in laryngeal cancer :

(i) The naked eye method, or diagnosis by direct inspection, sup-
plemented by clinical phenomena.

(2) Thyrotomy.

(3) The microscope.

Take it all in all, the first method is the most practicable and satis-
factory of the three. The author insists very strongly on the applica-
tion of the naked eye method of diagnosis in the case of malignant
tumors of the larynx. Every recourse and refinement of clinical diag-
nosis, including the exclusion of S3rphilis by the iodides, and tubercu^
losis by tuberculin, should be resorted to before appeal to the micro-
scope is made. By following the lead of the general surgeon, with the
means of clinical diagnosis at our command, together with the more
exact information concerning the naked eye appearances of the cut
surface of laryngeal neoplasms, we will soon be in a position where we
will be more and more independent of the pure pathologist for help in
diagnosis.

The objections urged against the indiscriminate removal of tissue
for examination, especially when done through the natural passages,
are as follows :

(i) It subjects the patient to the danger of autoinfection at the
point of incision and to metastasis elsewhere.

(2) It stimulates the local growth of the cancer.

266 ORIGINAL ABSTRACTS.

(3) Finally, the method is often inconclusive, misleading, and some-
times practically impossible.

In practically all cases of laryngeal cancer, death is due to metas*
tasis. In neighboring organs (the neck and mouth) metastasis takes
place with certainty and at an early date. It is, therefore, probable
that the glands of the neck are affected in cancer of the larynx, although
perhaps not recognizable by the senses of sight and touch, at a much
earlier period than is generally supposed. It is at all events safer to
assume this to be the fact than to accept the statement, unsupported by
definite anatomical proof, that cancer in the interior of the larynx
remains for a more or less indefinite period as a purely localized disease,
and does not get into the lympathics of the neck until a late stage of the
affection.

The author is very much opposed to intralaryngeal operation, and,
in a general way, is pessimistic in regard to the permanent cure by
surgical measures, although advocating the thorough removal of the
growth if seen in the earlier stages.

PROCTOLOGY.

By LOUIS JACOB HIRSCHMAN, M. D., Detroit, Michigan.

CUNICAL PROFUaOB OV PROCTOtjOGT IM TUB DBTmOlT COLLSCB OV BCBDICXMB.

LOCAL AND REGIONAL ANESTHESIA IN RECTAL

SURGERY.

Cooke (Janta, Volume XLVI, Number XXII) states that in the
last twenty months he has employed local anesthesia in seventy cases of
rectal and anal surgery comprising thirty-eight cases of internal hemor-
rhoids, two of prolapsus ani, five of fistula, nine of fissure, and sixteen
of external hemorrhoids.

Pressure anesthesia by means of injections of sterile water or weak
solutions of anesthetic drugs, was employed in all cases. For fissure
and external hemorrhoids, 0.25 to 0.5 per cent beta-eucain solutions
were used to anesthetize the integument in preference to sterile water
anesthesia. From personal experience Cooke feels warranted in claim-
ing for local anesthesia in rectal surgery, the following advantages :

( 1 ) It is simple, safe and effective.

(2) It eliminates the dangers and discomforts of general anesthesia.

(3) Pain at the time of operation is usually absent and always so
slight as to be easily borne.

(4) Postoperative pain is less by far than after the old methods.

(5) Time required for the operation is greatly reduced.

(6) Confinement to bed is rendered a matter of expedience, rather
than necessity.

(7) The period of detention from business is diminished fully one-
half.

MERALGIA PARESTHETICA. 267

(8) Under this method the hospital becomes a convenience and
luxury rather than a dreaded essential.

(9) It is a thoroughly reliable means of affording relief in many
cases which would otherwise be unsuitable for operation.

( 10) It robs these operations of their terrors and makes it possible
to reclaim this work from the hands of the "no knife" advertisers.

DERMATOLOGY.

By WILLIAM FLEMING BREAKEV. M. D., Ann Arbor, Michigan.

CUmCAL FItOPnSOB OP DBKMATOLOGT AlffD STFMILOLOGT IK THE UmVnSITT OT MICHIGAN.

AND

JAMES FLEMING BREAKEY, M. D., Ann Arbor, Michigan.

ASSISTANT IN DBKICATOLOGT IN TMB UNIVBHSTTV OF MICHIGAN.

"A NOTE ON THE TREATMENT OF SIMPLE WARTS BY
INTERNAL REMEDIES," ,

Under this titk Arthur Hall refers (British Journal of Dermatol-
ogy, March, 1906) to a case previously reported by him in which
numerous warts of the scalp, of two years duration, disappeared in two
to three weeks' time under the administration of mistura alba thrice daily.
Doctor Chalmers Watson had claimed that it was not the drug but
the purgation which accomplished the result, and Hall now reports a
case seeming to bear out that theory.

A girl, age fourteen, came to his clinic almost incapacitated by
reason of warts on wrists, hands, and fingers, she having counted three
hundred sixty-seven on one hand and wrist alone. She had always
been constitpated. Mistura alba (one-half ounce three times a day)
was prescribed and used five days. The bowels still being costive the
dose was doubled with still no improvement. After two weeks without
change confection sulphur and confection senna (one dram of each)
was substituted without result. Eleven days later the sulphur was
discontinued and an aloin and nux pill prescribed. Within a week
following this the warts began to shrink. The bowels were regular.
The treatment was continued for about two and one-half months,
at which time the hands and wrists were clean and but slight evidences .
of the warts remained on the fingers. This without the use of any
local treatment. j. f. b.

MERALGIA PARESTHETICA.

Doctor James C. White reports (Journal of Cutaneous Diseases,
April, 1906) the following case as of especial interest in view of the
fact that he has been unable to find the affection mentioned in any sys-
tematic work on dermatology or its symptomatology referred to in
chapters devoted to disturbances of sensation.

The patient, a male, age fifty-five years, became aware of disturbed

268 ORIGINAL ABSTRACTS.

sensations in the skin of the outer lower two-thirds of the ri^^t thigh
after his customary walk of four or five miles. The sensation was of
a tingling nature. From this time on— either standing or walking —
this region became the seat of a variety of perverted sensations,
tingling) tenseness, tearing, and sometimes a dull, deep ache. These
sensations were often usherd in by a growing sensaticxi in the part
The disturbances usually ceased on sitting or lying but might recur in
these attitudes from overstretching or twisting the leg. Deep pressure
over the area might also bring on the sensations. There was always
a sensation of something wrong on standing or walking. No pruritus
or throbbing or feeling of constriction was noticed. The area com-
plained of corresponded to the distribution of the cutaneous filaments
of the external cutaneous femoral.

Inspection of the leg showed little difference from its fellow, perhaps
a little paler. Induced hyperemia recedes more slowly than in its
fellow. The whole area was partially anesthetized, and over the patella
anesthesia was complete. Deep pressure over both legs showed little
difference in sensation. Dimensions of legs the same. Habits of
patient good.

Meralgia paresthetica is a condition always confined to the area
occupied in this case. It was first described about ten years ago by
Ben^ardt and Roth, and is described in works on nervous affections,
but Doctor White presents it as having claims for recognition in the
lists of cutaneous diseases. The neurologists have offered little that is
definite as to its cause.

Treatment is unsatisfactory, though massage gave partial and
temporary relief.

It has no apparent effect upon the general welfare of the patient.

J. F. B.

NEUROLOGY.

By DAVID INGLIS, M. D., Detroit, Michigan.
PROvnaoK or mmvoos amo icbmtal disbaski ik tmb dbtkoit coixacs or icBDicim.

AND

IRWIN HOFFMAN NEFF, M. D., Pontiac, Michigan.

ASSISTANT PMnXCIAN AT TMB BASTBBK MICMIOAK ASTLUM.

"TYPES IN MENTAL DISEASES."

William A. White has an article in the Journal of Nervous and
Mental Disease (April, 1906) on this subject. The author gives a
rather cursory review of the insanities, following Kraeplin's grouping
of the psychoses. He emphasizes the difficulty of differentiating some
of these types, and calls particular attention to the transitional forms,
deprecating the custcxn of analyzing mental diseases with a primary
tendency to group the mental trouble. He believes that this method of
attempting to g^oup the psychoses before a complete analysis of the
syndrome may lead to confusion. White gives a table, dividing the

AMERICAN MEDICAL ASSOCIATION MEETING. 209

psychoses into two great groups— dementing and nondementing
psychoses. These, with necessary subdivisions, form, as he believes,
a practical working classification. In conclusion he makes the following
summary:

(i) The necessity for a broad biological viewpoint in considering
the problems of mental alienation.

(2) The inconstancy and variability of t3rpes in mental disease as
shown by ,

(a) The occurrence of transition and intermediate forms.

(b) The overlapping of superposition of clinical types.

— ^in widely different clinical pictures.

(3) The desirability of a pause in the universal tendency to the
analysis of mental symptoms for the purpose of developing general
principles under which to group results.

(4) The suggestion that a great deal could be accomplished in this
direction by the study of certain symptom groups apart from the special
diseases which they more or less typify.

(5) The illustratk)n of what can be accomplished by this method by
its application to the dementia syndrome. i. h. n.

EDITORIAL COMMENT.

AMERICAN MEDICAL ASSOCIATION MEETING.

Boston is entitled to the glory of being the scene of the banner meet
of the American Medical Association, the unprecedented attendance of
over five thousand having been registered at the recent gathering of
the clans in that city. Whether the national event was the sole magnet
that attracted this multitude, or whether the practically coincident annual
meeting of the Massachusetts Medical Society, which contributed about
one-fifth of the number, was the potential factor in effecting high-water
mark on this occasion is immaterial insofar as concerns yielding the
palm to Boston for the greatest display of lapel insignia medical since
the inception of the national body. From the viewpoint of both scientific
and business achievement the meeting was likewise a memorable event,
but since the organization seems to be developing a commercial spirit
which bids fair to completely overshadow the intent of its original
promoters, the business aspects will be accorded preference in reviewing
some of the more important questions that received consideration.

4t 4t 4k

Doctor McMurtry, in his address before the House of Delegates,
congratulated the association on the removal of every vestige of the old
disagreements between New York medical men and the return of the
profession of that state as a united body. Attention was directed to the

270 EDITORIAL COMMENT.

dissatisfaction that prevails regarding the action of the Council of
Pharmacy and Chemistry in excluding advertisements of certain pro-
prietary medicines from the journal conducted by the association, the
contention having aroused a marked degree of antagonism toward the
supposed policy of the secretary-editor who was merely executing the
mandates of the trustees. Indeed dissatisfaction with the management
of the association generally has assumed such proportions that a resolu-
tion was introduced requesting the appointment of a committee to inves-
tigate the affairs of the secretary and treasurer, but the shortsightedness
of zealous friends was responsible for tabling the measure and thereby
unfortunately committing the officers to unwarranted suspicion. If The
report of Doctor Simmons disclosed the informaticm that there were
23*636 members in the association, 4,351 having affiliated therewith
during the past year. ^ Doctor Happell, chairman of the Board of Trus-
tees, reported that the association was in a flourishing condition finan-
cially, the assets being nearly $238,000. During the past year the income
from all sources aggregated about $275,000. The expenses for this period
were approximately $250,000, leaving an annual income of $25,000 to
augment the total net assets to $247,500. With an indebtedness of only
about $10,000 the above rendering certainly justifies continuance of the
incumbent financial management, f Doctor Reed, of the Committee on
Medical Legislation, reported the recommendation of an appropriation
to facilitate the formulation of a bill for the department of public health
and the payment of current expenses of the Committee. If Doctor
Rodman, of Philadelphia, called attention to the necessity for uniform-
ity of license g^nting in the various commonwealths of the United
States, and while deploring the improbability of inunediate naticmal
control of licensiation, suggested that the Council on Medical Education
should be empowered to issue licenses to practice medicine in any state.
If The report of Doctor Keen, chairman of the Committee on the Walter
Reed Monument Fund, showed that $19,700 was m hand and $1,200 in
subscriptions outstanding. The ungratefulness of human nature is
manifest in the fact that quarters rendered immune to yellow fever by
the discovery of Doctor Reed ccmtributed the smallest amounts to his
memory. If A series of resolutions endorsed the conduct of Secretary
Simmons and disclaimed any intention on the part of the American Med-
ical Association or the State Medical Societies to injure the independent
medical journals owned or edited by physicians — ^the later declaration
precipitating in face of the fact that the independent medical journals
are confronted by a system of competition which frequently proffers
advertising space for a pittance and invariably renders puUication
without price. However, this is considered legitimate privilege in
business transaction. It is likewise considered legitimate criterion in
judging valuation.

* 4: 4t

The literary program contained many papers that afforded excellent
food for thought and action. Doctor Mayo, in his presidential address.

AMERICAN MEDICAL ASSOCIATION MEETING. 271

discussed "The Medical Professicm and the Issues which Confront It,"
considering the profession and the public ; public health legislation ; med-
ical education, state licensure, and reciprocity; relations to insurance
companies, corporations, et cetera ; the practice of medicine as a business ;
and concluded with a peroration on medical progress, from which this
beautiful passage is reproduced : "What are the rewards of so laborious
a life? They cannot be measured, because there is no standard of com-
parison. To realize that one has devoted himself to the most holy of all
callings, that without thought of reward he has alleviated* the sufferings
of the sick and added to the length and usefulness of human life, is a
source of satisfaction that money cannot buy. I know many a man
grown gray in the profession with little of a tangible nature to show as a
result of his work, but who is not only contented with his lot, but proud
to have served in the ranks, and who looks back on a life of privation and
hardship for the benefit of humanity as a privilege which he is thankful
has been vouchsafed him." ^ Among the various contributions to the
sections were several which discussed' the conduct and practices of
physicians themselves. Doctor Jacobi, of New York, read a paper on
"Quackery," in which he declared that physicians were responsible in
great degree for the self-dosing with patent medicines. Many doctors
prescribe nostrums and support medical journals that publish "reading
notices," that publish advertisements of drugs in the guise of "original
articles," and that alternate medical with advertising pages. If Doctor
Dock, of Michigan, discussed "Proprietary Medicines and Their
Abuses." The exclusion of advertising laudatory of these products
would not be likely to elevate the morals of physicians already employ-
ing them in practice. The most efficacious proprietary medicaments
would continue to be manufactured and advertised, but crude exper-
imentation could be discouraged by treating the advent of new drugs
as lightly as one would treat a new phase of mental healing or a new
application of massage. The abuse of proprietary medicines sprang
partly from the exaggeration of legitimate commercial methods, and
partly frcMn the credulity of the medical profession. It is within the
province of the profession to determine the virtue and vogue of every
medicinal product recommended for the treatment of disease. IfAt a
meeting of medical editors, Doctor Pilcher, of Pennsylvania, contrib-
uted a paper in which medical editors were classified and defined, a
summary of opinion being embraced in the following: "We conclude,
then, (i) that while medical journalism as a prop to practice and a
bridge over the impecuniosity of early professional years may be of some
advantage to the profession as well as to the temporary editor ; (2) that
while medical journalism for the purpose of developing special lines of
• professional and mercantile work may be of much service to many of the
profession ; (3) that while there are a small number of men who possess
the exceptional executive and literary ability necessary to conduct pro-
fessional and editorial work at the same time — ^the medical journalism
of the twentieth century increasingly demands the whole intellectual and

272 EDITORIAL COMMENT.

physical energy of its editorial conductors in the presence of the great
aggregation of professional atoms which is daily falling upon the profes-
sional field to be excavated and investigated, and the during away of
which, for the benefit of the twentieth century practitioner, will demand
the entire absorption of the mind, soul, and body of the conscientious
medical editor who really desires to be a helper to the profession and a
leader in the medical work of the age."

ANNOTATIONS.

THE INFLUENCE OF MINERAL WATER ON MICROBES.

Rheinbolt, in a German publication, describes his experiments on
the bacillus prodigiosus with radioactive mineral water. That minerals
of all kinds exert a deteriorating influence <mi bacteria is a well-known
fact, and that mineral water is also an inhibitant to bacterial growth was
disclosed by the experiments of this scientist. While old water, bottled
for commercial purposes, seemed to have lost its attenuating power,
fresh specimens, taken from the spring, destroyed the organisms in a
boullion culture after a contact of four hours, the activity of the water,
however, decreasing after this time. Efforts to recharge the liquid with
radium emanations proved to a degree futile, and this fact is responsible
for the conclusion that mineral water possesses inhibitory properties
other than are represented in this metal.

INVESTIGATIONS BEARING ON ANIMAL INTELLIGENCE.

The study of animals, the degree of their intelligence, the acuteness
of their vision, and the capacity of their comprehensicMi is indeed interest-
ing. However, owing to our inability to decipher their vernacular, or
whatever phonetic means of communication they may possess, we are
unable to successfully penetrate their mentality. Zell has studied the
subject quite comprehensively, and in a contribution to a German publi-
cation details his observations. That monkeys are equipped with a keen
sense of sight he is convinced, and that their power of discrimination is
above the ordinary he determined when studying the quadrumana in the
Berlin Zoological Garden. Contrary to the usual spirit of audacity which
characterizes these animals, one of them utterly ignored the visitors and
concentrated her attention on a street vehicle, seemingly wrapped in deep
thought. On asking the keeper the cause of her concern the observer
was informed that instead of the customary horse the conveyance was
attached on this occasion to a donkey, and the aural appendages and
other equine dissimilarities had incited her curiosity. Monkeys are
equipped with a comparatively poor olfactory apparatus, and must
depend almost entirely upon their sense of sight to warn them of the

PHYSICIANS AND PHILOSOPHERS. 273

approach of animals of prey and other malefactors. Dogs, on the other
hand, so far as scientists have been able to determine, have an excellent
sense of smell, but of the power of their optical adjustment little is
known. Deer and roebuck have comparatively poor eyes but excellent
noses. Observation has taught that animals are more vindictive to
enemies than is man, and in consequence of the constant vigil which
beasts of the jungle must maintain on account of the murderous assaults
of preying foes, nature has wisely endowed them either with keen percep-
tion or acute sense of smell.

STOICISM OF EARTHQUAKE SUFFERERS.

The stoicism with which Californians view the calamity to the city
of San Francisco is displayed in an article which lately appeared in a
western publication. In comparing the deaths resultant from the earth-
quake to those sustained in recent American catastrophes the utmost
optimism is exhibited. In the Iroquois theater conflagration in Chicago
more than five hundred persons met death, and over one thousand lives
were sacrificed in the burning of the steamer "Slocimi" in New York
harbor. Thus it will be seen that sinc^e only three hundred thirty-three
persons succumbed from fire and quake in the California metropolis, the
loss, while appalling, is c<Mnparatively small. The author argues that
within the course of a few weeks more than three hundred persons would
have died from natural causes, and inasmuch as hundreds of births will
occur in San Francisco within a year, the depopulating effect of the dis-
aster is not so severe as would at first be imagined. Indeed, when con-
trasted with other catastrophes, the death list is insignificant.

CONTEMPORARY.

PHYSICIANS AND PHILOSOPHERS.

[pmoraaaoK chaklbs william supkr, ov omio vnivbrsitt, in populak scibmck monthly.]
{C»niinu4d from ^ag» 2t3b.)

According to Homer and Herodotus, the healing art was discovered
or invented in Egypt. The Odyssey tells us that there every man is
a physician skilled beyond human kind. Mention is also made of the
many plants possessing medicinal properties. Oculists are said to
have been particularly numerous, and many prescriptions for diseases
of the eye have been found among the papyri. Artificial and gold-
filled teeth have also been met with both in Egypt and in Etrurian
tcrnibs. The practise of medicine was, however, purely empirical, and
the rules followed in the treatment of particular diseases were often
of great age. The second king of Egypt is said to have been a physi-
cian, and another is reported to have written a book on anatomy. The
private physicians of both Cambyses and of Darius were Egyptians.

274 EDITORIAL COMMENT.

The name of the latter brings to mind that of his son Artaxerxes whose
private physician was a man of considerable importance in his day,
outside of his profession. Ktesias was a native of Knidos, a contem-
porary of Hippocrates, and no doubt personally known to him. Here
we have again the philosopher and the physician in the same person.
After acquiring considerable reputation in his own country he had the
misfortune to fall into the hands of the Persians. Subsequently he
was introduced at court, which proved the beginning of his good
fortune. After the battle of Cunaxa he healed the wound inflicted upon
his master by the brother of the latter. Later he was employed on a
diplomatic mission to his native land; and thus after an absence of
seventeen years returned home about 398 B. C, to remain for the rest of
his life. That he was well treated by the master whose slave he became,
according to Persian parlance, and had abundant opportunities for
study, is evident from the fact that he compiled a 'History of Persia,'
a work in which he charged Herodotus with frequent falsehoods in
what he relates about that country. His scholarly tastes are evinced
by this extensive collection, as it must have been, since it was divided
into twenty-three books. He also composed a small work on India
and one on geography. He is not known to have left any medical
writings, and his reputation for impartiality as a historian is not very
good. Still it must be regarded as a great misfortune that his extant
remains are so meager.

In later times many Egyptian physicians practiced in Rome ; for to
have studied in the land of the Nile, or, still better, to have been bom
there, was regarded as a special recommendation. Here, too, magic
formulas of all kinds were in frequent use, not only in the compound-
ing of medicines, but in their application. According to Pliny cadavers
were dissected by order of the Ptolemies for the purpose of studying
fatal diseases. But it can hardly be inferred from this statement that
anatomy was regularly pursued in this way, or that dissection was a
common practice.

Pliny, who had no very high opinion of the medical fraternity for
reasons that will appear farther on, makes the assertion that Rome
managed to get along six hundred years without physicians. This is
manifestly an exaggeration, since many Greeks professed the healing
art in the imperial city much" earlier than 150 B. C. But neither did
Rome produce a philosopher in the proper sense of the term ; certainly
no man who loved wisdom for its own sake. The Romans were, how-
ever, an exceptionally healthy people, owing to their fondness for out-
door life. This is demonstrated by the rapidity with which they recov-
ered from repeated disasters. Once in a while their capital was invaded
by a contagious disorder, then all who could do so left it until the
scourge had spent its force, when affairs resumed their natural channel.
In fact this was the usual course everywhere until very recently, when
the real nature of such diseases was discovered. The ancient Romans
were also a singularly hard-headed and practical people ; consequently

PHYSICIANS AND PHILOSOPHERS. 276

they were almost entirely free from the long list of complaints that
are more or less due to the uncontrolled or uncontrollable imagination.
Shortly after the Punic wars, but especially under the empire when
luxurious habits due to the influx of wealth from the east had debili-
tated the naturally robust constitutions of the higher classes, nervous
disorders, along with many others, were inevitable. Then quacks,
charlatans, medicasters, soothsayers, magicians, astrologers and what
not found a ready market for their wares. They played upon the cre-
dulity of the populace and preyed upon their purses because there was
money in both the playing and the preying. No small portion of them
probably were shrewd enough to disguise some real medical knowledge
under a mass of hocus pocus in order to influence the imaginations of
their patients. Well might Ovid say as others had said before him —
and since, too—mundus vult decipi (people like to be deluded). Phy-
sicians still give to their patients who insist 'on taking something' bread
pills, colored water and other equally potent or impotent remedies. It
would be manifestly unfair to charge a physician with dishonesty
because he practices a harmless ruse upon a patient who can be helped
in no other way so easily.

"Dismissing faith in the confused creeds of the heathen world, he
reposed the greatest faith in the power of human wisdom. He did
not know (perhaps no one in that age distinctly did) the limits which
nature imposes on our discoveries. Seeing that the higher we mount
in knowledge the more wonders we behold, he imagined that nature not
only worked miracles in her ordinary course, but that she might, by
the cabala of some master soul, be diverted from that course itself.
Thus he pursued science across her appointed boundaries into the land
of perplexity and shadow. From the truths of astronomy he wandered
into astrological fallacy ; from the secrets of chemistry he passed into
the spectral labyrinth of magic; and he who could be skeptical as to
the power of the gods was credulously superstitious as to the power
of man." Such are the thoughts that Bulwer-Lytton, in the Last Days
of Pompeii, puts into the mind of one of his characters, the Egyptian
Arbaces. The reasoning by which such men justified the employment
of their superioi: knowledge and insight to dupe the credulous was
half philosophy, half knavery. If a man is the possessor of power
unknown to the multitude except in its effects, why has he not the
right to use it? — to use it first of all to enhance his authority and to
draw from such authority the advantages that seem to him most desir-
able ? We may well admit that a man of this stamp may have had an
inward feeling akin to what we call conscience that would justify his
attitude toward his fellows — ^yet he did not consider these Romans
fellow men of his — but it was wholly of the intellect. Such a man is
as much a philosopher as were the sophists of an earlier age, and, we
may add, of our own day. They apprehend clearly certain superficial
verities, but cease to inquire farther after they have discovered what

276 EDITORIAL COMMENT.

they think needful and sufficient for their own aggrandizement Far
different was the class of witches, one of whom is introduced in the
same novel. Against these Horace frequently raises his voice, as do
also others of the rationalizing Romans. They are ignorant, and, in
most instances, as much the dupes of their own juggleries as their
victims. Every man who goes through the world with his mind alert
can see specimens without especially looking for them. It is doubtful
whether any man has ever lived who had not at least a modicum of
superstition in him. However much we may know and however far
we may be able to pry into nature in some directions, there are others
in which our vision is barred and the unknown is literally within arm's
length. The mystery of life and death has always been so profound,
as it still is, though in a different way, that we need not wonder at the
strange aberrations which so many persons fell into, who were in most
matters little likely to be carried away by delusions. Sleep, 'the twin
brother of death,' has from time out of mind been regarded as an
excursion into the realm of departed spirits. If, as many believe, our
consciousness is never coextensive with our personality, there are yet
many discoveries to be made not dreamt of in the philosophy of most
of us. Our will as an integral part of ourselves is the resultant of so
many forces and, with the majority, is so little under control of rational
motives, that it often plays fantastic tricks, not before high heaven
alone, but almost anywhere.

The will of each individual as modified, at least in action from
moment to moment, is like a ball thrown into a grove. It strikes one
tree, then another and another, and no one can predict with certainty
where it will come to rest. This element of chance, of Tyche, in the
affairs of men, this incalculable calculus of probabilities, pervades in
a remarkable degree the literature of ancient Greece and Rome. It
made many feel that, do what they would, they were doomed to be
thwarted in their plans. It was only those who, like Socrates, Epictetus
and a few others, maintained that the chief end of man is to be found
in motives rather than in outward results, who were never thrown out
of their philosophical poise by the strange vicissitudes of life.

It is a far cry from the Greeks to the Saracens, though farther in
time than in space. Here we find philosophy, or rather metaphysics,
and medicine more intimately associated than at any other time or
among any other people. Every one of the ten or twelve men who
became prominent in Arabian philosophy was a physician. In fact the
Arabs treated philosophy as a branch of astronomy and the healing art.
The latter served a practical purpose, as did also the former in so far as
it was dealt with as astrology. Arab philosophy was, however, some-
thing very different from the science that bore the same name among
the Greeks. They studied philosophy, or rather they philosophized,
as a man would study navigation on a ship lying at anchor. Albeit
they were in this respect at no greater disadvantage than the school-
men. The one party was chiefly concerned to make any discoveries

PHYSICIANS AND PHILOSOPHERS'. 277

they might light upon hannonize with the Koran and Aristotle; the
other with the Bible and Aristotle, with a little spice from Ptolemy
thrown in. Al-ldndi, the philosopher par excellence of the Arabs,
flourished in the tenth century. He wrote on almost every imaginable
subject from arithmetic to astronomy, though under the former he dis-
cusses the unity of God ; his arithmetic was therefore something totally
different from that which forms the schoolboy's triangle with readin'
and 'ritin'. So far as is at present known all his works are lost, except
those on medicine and astrology. Roger Bacon ranks him in some
respects close to Ptolemy. Al-farabi was a contemporary of the pre-
ceding and is generally regarded as the earliest of the Arabian philos-
ophers. However, medical science and even surgery could make little
progress where the knowledge of human anatomy was so inadequate.
The Koran denounces as unclean every person who touches a dead
body, and an article of Mohammedan faith forbids dissection. We
should remember, nevertheless, that the founder of anatomy, Vesalius,
was sentenced to death by the Inquisition as a magician, and only par-
doned on condition that he make a pilgrimage of penance to Jerusalem.
This journey cost him his life. And it is probable that he would not
have got off even on these relatively hard terms had he not enjoyed the
favor of Philip H of Spain, who esteemed him highly for his medical
skill. We have the name of one Arab physician, Abdallatif of Bagdad,
who was well aware that anatomy could not be learned from books,
strange as it may seem that historians have thought it worth while to
place to any man's credit a truth so easily apprehended. The same
authority avers that Moslem doctors studied that branch of anatomy
known as osteology by examining the bones of the dead found in cem-
eteries. Averroes of Cordova fills a large place in the history of Moor-
ish philosophy in Spain about the middle of the twelfth century. But
in medical renown he ranks far below Avicenna of Bokhara, who
flourished about a century and a half earlier. He was teacher of both
philosophy and medicine in Ispahan. His medical works seem to have
been the chief guide in this branch in Europe for almost five centuries ;
their sway was not broken until the beginning of the seventeenth cen-
tury. It is strong and yet painful testimony to the inherent stupidity of
mankind, physicians not excepted, that the doctrines of Avicenna are
little more than what is found in Galen somewhat modified by Aris-
totle ; and, as we have seen, Galen represents no great advance upon
Hippocrates. Alas for the human race that it has always been so much
easier to memorize than to think and to investigate! The medical
science and practice of the Arabs was confined chiefly to surgery and
the empirical treatment of internal diseases. There was no lack of
victims in view of the constant wars in which the califs were engaged,
and no lack of opportunity for the study of disease in its various forms
in the hospitals which some of them founded in various parts of their
domains.

[TO Bl CONTINUED.]

278 MEDICAL NEWS.

MEDICAL NEWS.

THE NATIONAL MEDICAL ELECTION:

Doctor Joseph D. Bryant, of New York City, was elected pres-
ident of the American Medical Association at its recent meeting in
Boston. Other officers chosen on this occasion are as follows: First
vicepresident, Doctor Herbert L. Burrell, of Boston; second vice-
president, Doctor Andrew C. Smith, of Portland ; third vicepresident,
Doctor David S. Fairchild, of Des Moines; fourth vicepresident.
Doctor William S. Foster, of Pittsburgh; general secretary, Doctor
George H. Simmons, of Chicago ; treasurer, Doctor Frank Billings, of
Chicago; trustees, Doctor Malcolm L. Harris, of Chicago, DoctcM*
William H. Welch, of Baltimore, and Doctor Miles F. Porter, of Fort
Wayne.

COMMENCEMENT SEASON CLINIC.

Clinic week is always an important feature of commencement sea-
son at the Detroit College of Medicine, but the event this year is
pronounced more consequential than ever before, as many as three
hundred witnessing some of the clinics, and five hundred being con-
servatively estimated as the total attendance. In addition to the regular
teaching force of the college, clinics were conducted by Doctor George
Dock, of Ann Arbor, on diseases of the heart; Doctor Edward G.
Tuttle, of New York, on rectal diseases; Doctor Bart E. MacKenzie,
of Toronto, on orthc^dic surgery; and Doctor Howard A. Kelly, of
Baltimore, on operative gynecology. The advent of the scientific and
social features of the occasion was marked by a symposium on "Crim-
inal Abortion" before the Wayne County Medical Society, the partici-
pants being Doctor Howard W. Longyear, of Detroit, who discussed
the question from the medical standpoint ; Attorney Charles Lightner,
of Detroit, who considered the legal aspect of the question ; and Rev-
erend Father Command, of Trenton, who defined the attitude of the
Church toward the murderous practice.

THE PENINSULAR GATHERING OF PHYSICIANS.

The forty-first annual meeting of the Michigan State Medical
Society was held at Jackson, May 23, 24, and 25. The program
embraced the titles of over fifty papers, besides three orations and two
addresses, the latter being delivered by Doctor John B. Murjrfiy, of
Chicago, and President David Inglis, of Detroit. "Education" was
the subject of the presidential discourse, and the views enunciated con-
template not only better means of educating the physician but better
means of educating the public as well. The trend of ideas is especially
reflected in the suggestion that county societies disseminate informa-

LIFE INSURANCE EXAMINATION FEES. 279

tion among the laity regarding the prophylaxis of venereal diseases;
that a committee on medical educaticm be appointed from the State
Society to cooperate with the Q>uncil of the American Medical Asso-
ciation; that amalgamation of medical schools affords the greatest
efficiency in properly training medical students, and hence the desira-
bility in Michigan of merging the State University medical school and
the Detroit College of Medicine. The quality of the papers was equal
to the average of previous meetings, while the symposiums in the
sections afforded exceedingly delightful variation. The Society
recommended the c(xnbination of medical colleges; addition to the
faculties of medical colleges of a chair on Professional Ethics ; investi-
gation of contract practice for fraternal orders and for poor commis-
sioners ; refusal to accept reduction of fees for life insurance examina-
tions ; and modification of existing laws to enable more efficient deal-
ing with tuberculous cattle. It was decided to return to a two-days'
session and to omit the orations. A vote of thanks was tendered
Doctor Leartus Connor for services rendered in reorganizing the State
Society, and a committee was appointed to select a testunonial for
Doctor Andrew P. Biddle in recognition of his services as secretary.
The following officers were elected for the ensuing year: President,
Doctor Charles B. Stockwell, of Port Huron ; first vicepresident. Doctor
William Fuller, of Grand Rapids ; second vicepresident. Doctor Edward
T. Abrams, of Dollar Bay; third vicepresident, Doctor Delbert Rob-
inson, of Jackson; fourth vicepresident. Doctor Allison R, Stealy, of
Charlotte. The following were elected chairmen of sections: Med-
icine— ^Doctor Joseph B. Whinery, of Grand Rapids ; Surgery — ^Doctor
Louis A. Roller, of Grand Rapids; Gynecology — Doctor Walter H.
Sawyer, of Hillsdale. The next meeting will be held at Saginaw.

LIFE INSURANCE EXAMINATION FEES.

The question of compensation for life insurance examinations was
considered at the recent Jackson meeting of the Michigan State Medical
Society, and the concensus of opinion was expressed in the following
preamble and resolutions: '

Whereas, Many of the Life Insurance Companies havQ notified their
medical examiners of a reduction of the examining fee from $5.00 to
$3.00, and

Whereas, We, as physicians, realizing the responsibility incident to
proper examination of the individual, believe such reduction to be
unjust, therefore, be it

Resolved, That the House of Delegates, in session assembled, does
hereby declare such reduction to be unjust, and respectfully requests
that no physician legally authorized to practice medicine in Michigan,
accept such reduction of fees.

Resolved, That it is the sense of the House of Delegates that here-
after in such examinations for life insurance, the minimum fee shall
be $5.00.

280 MEDICAL NEWS.

Resolved, That the several component societies forming this State
Society, be requested to adopt these resolutions.

Resolved, That a copy of these resolutions be mailed to the several
life insurance companies that have reduced the fee from $5.00 to $3.00.

At the Boston meeting of the American Medical Association, Doctor
Mayo, in his presidential address, referred to the question of fees for
life insurance examinations in the following terms :

"We come now to consider some abuses from which the physician
suffers. It is a matter of professional pride that, in the general con-
demnation of the life insurance companies, although every other part
of the control has been shown to be corrupt, no breath of scandal has
touched the medical department. Yet the local examiner has the most
cause of all to be dissatisfied. The New York Life, some years ago,
cut the fee for examination forty per cent, apparently not as a matter
of ecgnomy, for at that time the most corrupt practices existed, but
rather to enable the agent more easily to pass 'new business' at any
cost. This action has lately been imitated by the Equitable and some
others and has resulted in forcing the resignation of many of their best
examiners. The general officers have taken great credit on themselves
for voluntarily reducing their salaries twenty per cent. It is a rank
injustice that the one body of men who have emerged clean from the
insurance scandals should suffer the most for the crimes of others.
A thorough medical examination to prevent fraud by the admission of
unsafe risks is essential. With few exceptions the line companies pay
a fair fee and less should not be accepted. The casualty Companies,
such as the Maryland, are the worst offenders, and some concerted
action should be taken to compel them to mend their evil ways."

Acting upon the suggestion of the President the following resolu-
tion was introduced and referred to the Committee on Miscellaneous
Business :

Resolved, That a standing committee on insurance is hereby created
to consist of five members, two of whom shall be the President and
Secretary, and the other three to be nominated by the President and
confirmed by this House of Delegates. It shall be th duty of the com-
mittee to consider the relations and duties of the medical profession of
this country to the insurance business, both companies and policy
holders to confer, treat and act with authorized representatives of any
of these interests, and it is authorized to speak and act for the profes-
sion in all matters relating to its duties and to give publicity to its
plans and purposes at any time through The Journal, or otherwise, as
may be deemed best.

This committee, which includes, besides the President and Secretary,
Doctors E. Elliot Harris, Albert D. Price, and William D. Haggard,
submitted the following resolution to the House of Delegates :

Resolved, That a committee be created to consist of five members,
two of whom shall be the President and the President-elect and the

LIFE INSURANCE EXAMINATION FEES. 881

Other three to be nominated by the President and confirmed by the
House of Delegates.

That they shall consider the insurance question in its relation to the
medical profession, and it shall have power to act and confer with the
representatives of the insurance cc«npanies and policy-holders on behalf
of the medical profession represented by this Association.

It shall give publicity to its plans and purposes at any time in The
Journal or as may be deemed best.

That the resolution of Doctor D. M. Work, of Colorado, asking for
an endorsement in the matter of the examination fee question which
has been confirmed by many county medical societies.

That the Committee recommends that it is in spirit with it ; yet in
view of the fact that a committee is created to deal with these questions,
it asks that the resolution in question be referred to the Committee on
Insurance.

The following Committee on Insurance was tjien appointed by the
Chair:

John H. Musser, Pennsylvania, Chairman ; William H. Mayo, Min-
nesota; Joseph N. MacCormack, Kentucky; Joseph D. Bryant, New
York; Frank Billings, Illinois.

The resolution of Doctor Work alluded to in the resolutions of the
Committee on Miscellaneous Business, is as follows:

Resolved, That the American Medical Association heartily endorses
the action of many of its component county societies in their refusing
to accept a reduction of the fees heretofore paid for life insurance
examinations by certain so-called old-line companies.

This is the status of the matter as considered by the Michigan State
and American Medical Associations. At the seventh annual meeting
of the American Association of Life Insurance Examining Surgeons,
which was lately held in Boston, the question of fees was discussed.
This association is composed of physicians who are closely identified
with the present agitation, and consequently the following preambles
and resolution, adopted by that body, will be of exceeding interest :

Whereas, It is generally understood by every practitioner through-
out the country that the examiner who does his full duty must often
cause the rejection of undesirable risks and the consequent loss of busi-
ness to the company and of commissions to the soliciting agent; and,

Whereas, The interests of the insured and the welfare of the com-
pany represented by the examiner make it necessary for him to exercise
his judgment, to make a careful diflFerentiation of risks and to try by
every means in his power to recommend only those applicants whose
physical condition is up to the standard and whose examination dis-
closes no undue influence which might prevent the living out of the
estimated expectancy; and,

Whereas, Recent disclosures in connection with life insurance aflFairs
have demonstrated (i) inexcusable negligence, (2) criminal careless-
ness, (3) dishonest practices on the part of the highest executive

282 MEDICAL NEWS.

officers, and a total abandonment of the responsibility always pertaining
to a trusteeship, in a concerted e£Fort for personal profit ; therefore be it

Resolved, That we favor the complete separation of the medical
from the executive department of every mutual insurance company.

We favor the election of the medical director in the same way and
manner as the election of the executive officers, namely, by diro:t vote
of the policy-holders.

We favor suitable legislation in all States, with a view of making
this recommendation effective.

We depreciate the action on the part of certain state and country
medical societies to assert that members shall be expelled from mem-
bership or shall be deprived of the privilege of consultation with their
fellows unless they agree under no circumstances to make an examina-
tion for less than $5. We agree that a reduced fee is inadequate to
the value of the service rendered, but we assert that no hardship should
be imposed upon the individual practitioner. We favor in place of this,
to enter an earnest protest against the attempt of certain companies to
reduce the fee. We assert most positively that economy in insurance
methods should not begin with the medical examiners — ^it should take
cognizance of the irregularities — ^to use no harsher word — ^which the
Armstrong investigation has brought to light It should favor reform,
but it must maintain an efficient corps of medical examiners, which is
only possible by paying a fee to some degree commensurate with the
importance of the service rendered.

MINOR INTELLIGENCE.

Doctors Charles D. Aaron and Gilbert S. Field, two Detroit
physicians, are in Europe.

The next meeting of the American Medical Association will be
held at Atlantic City, New Jersey.

The osteopathic licensing bill, which recently passed the New York
Senate, was afterward revoked by the Assembly.

Doctor Hal C. Wyman, of Detroit, and Miss Lulu Weeks, of
Mount Vernon, New York, were united in marriage on June 12, at
the home of the bride.

An amalgamation of the old territorial medical associations of
Oklahoma and Indian Territory has been effected, and the new organ-
ization will henceforth be known as the Oklahoma State Medical
Association.

This year's meeting of the British Medical Association will be
held in Toronto, Canada, ^rom August 21 to 25. A large attendance
is anticipated both from England and from the United States. The
address in Medicine will be delivered by Sir James Barr, and the
address in Surgery by Sir Victor Horsley.

MINOR INTELLIGENCE. 283

Doctor F. F. Westbrook has been elected to the deanship of the
Minnesota University department of medicine and surgery, vice Doctor
Parks Ritchie, resigned.

Doctor George Blumer, formerly professor of pathology and bac-
teriology in the Albany Medical College, has been appointed to fill the
chair of medicine at Yale University.

A BILL appropriating a total of $350,000, or $50,000 annually for
seven years, for the work of exterminating the mosquito has been
signed by Governor Stokes of New Jersey.

The Order of the Rising Sun has been cgnferred upon Doctor
Jokichi Takamine, the well-known Japanese chemist of New York
City, by His Majesty, the Emperor of Japan.

Plague continues to reap a fearful harvest in India. During the
week ending April 28 over one thousand seven hundred deaths out of
a possible twenty thousand cases were reported.

Doctor Bacon, a prominent Connecticut physician who died
recently, left a legacy of $100,000 to the Hartford Medical Society.
The bequest will be utilized as an endowment fund.

Doctor Theodore A. Felch, of Ishpeming, has been appointed a
member of the Michigan State Board of Registration in Medicine, vice
Doctor Joseph B. Griswold, of Grand Rapids, resigned.

Mayor McClellan, of New York City, has appointed a commission
to cooperate with a like body from Jersey City in the establishment of
protection of the waters of the harbor against pollution.

The Health Department of Chicago will shortly gain possession
of the eight municipal ambulances which have been under police con-
trol. The vehicles will then be under medical supervision.

The new medical buildings of Harvard University will be dedicated
this fall, the ceremonies being scheduled for September 25 and 26,
1906. Faculty invitations have already been issued to alumni.

Doctor Albert Becket Lamp, formerly of Harvard University,
has been appointed to the directorship of the Havemeyer Laboratory
of Chemistry, New York University, vice Doctor Morris Loeb.

In connection with the opening of the new cancer research labora-
tory at Heidelberg, an international congress on the subject is con-
templated. The event will be held from September 24 to 27, 1906.

Doctor Charles W. Pilgrim7 until recently superintendent of the
Hudson River State Hospital, has been appointed to the presidency
of the New York State Lunacy Commission, vice Doctor William
Mabon, resigned.

The great prevalence of typhoid in Pittsburg and vicinity has led
the Pennsylvania Commissioner of Health to demand that the cities and
villages situate on the tributaries of the Allegheny disinfect all refuse
before dumping it into the streams.

284 MEDICAL NEWS.

The American Journal of the Medical Science which, untfl recently,
has been under the editorial control of Doctor Francis R. Packard,
will henceforth be guided by Doctor Aloysius O. J. Kelly, who has
been elevated to the editorial tripod.

Professor Wilhelm Ostwald has resigned the chair of chemistry
at the University of Leipzig. Displeasure caused by the indifference of
coworkers at the institution toward his chemical researches is said to
be the reason for the relinquishment.

Milwaukee has an ordinance which compels physicians to report
injuries which incapacitate the victom for a period of two weeks or
longer. An average of more than one hundred seventy-five a month
has been recorded thus far this year.

The Lyman D. Morse Advertising Agency, well-known medical
advertising purveyors, has increased its scope, and will henceforth
be known as the Morse International Agency, with offices at 19 West
Thirty-fourth Street, New York City.

The effectiveness of the sanitary regime instituted by the Amer-
icans in the canal zone is apparent. According to the last official report,
that region was infested with only one case of yellow fever, and disease
of all kinds is rapidly being eradicated.

The House of Representatives passed the Pure Food bill by a vote
of 240 to 17 on the 23d instant. The enactment differs considerably
from the original measure proposed by the senate, having been subjected
to the adoption of several amendments.

The recent death of Doctor Louis A. Wiegel, of Rochester, New
York, from burns received in experimenting with the ;r-rays, should
serve as a warning against undue exposure, especially of the hand,
when operating radiographic apparatus.

The Minnesota State Board of Health has decreed that henceforth
tuberculous teachers shall not be employed, inasmuch as confinement
in school buildings not only militates against the recovery of teachers
but endangers the health of the children as well.

The plaintiff .in a damage suit which recently occurred in Nebraska
was granted a verdict for $600 against a physician for injuries allied
to have been received in an jr-ray examination for the detection of a
vesical calculus. Damages to the extent of $6,000 were claimed.

Doctor John J. Marker has been reappointed general superin-
tendent of the Wayne County Home at Eloise. Other positions filled
by the Superintendents of the Poor are: assistant superintendent,
Doctor William B. James ; house physician. Doctor Romeo H. Earl.

A SOCIETY for the promotion of cremation has been formed in
Belgium. Inasmuch as this method of disposal has not gained foothold
to an appreciable degree in that country the new organization will
conduct a campaign by means of lectures, tracts, expositions, et cetera.

MINOR INTELLIGENCE. 286

The French government has accorded Madame Curie, wife of the
discoverer of radium, a pension of 12,000 francs per annum. Besides
this income she will have the salary connected with the chair of Physics,
in the University of Paris, to which she has recently been appointed.

The Philadelphia Board of Education is agitating the advisability
of employing a corps of trained nurses to work among the school
children of that city. Because of the appropriation incident to the
departure, such a bill would be likely to receive a negative vote in the
city council.

The Buffalo city hospital for the care of patients suflFering from
contagious diseases is rapidly nearing completion. The erection of
the new building has necessitated an expenditure of over $50,000, and
in range of equipment the institution will be one of the best appointed
in the state.

The study of alcoholism has been introduced into the curriculum
of the University of Berlin. The subject will be demonstrated from
all phases — the influence of alcoholic indulgence on the mental develop-
ment of the young, its relation to insurance, its effects on the physical
powers, et cetera.

Cocktails adulterated with wood alcohol are responsible for two
deaths which occurred recently in Brooklyn, New York. A ten-gallon
keg of the wood product was found on the premises of the saloonkeeper
who dispensed the decoction, and the rascal has been arrested on a
charge of homicide.

A charter was recently granted in New York to the American
Institute for Scientific Research, which had its inception in the Society
for Psychical Research. The new body was organized primaril]f to
investigate conditions of abnormal psychology and to place the study
on a scientific foundation.

New Rochelle, New York, is to have a new hospital. Mr. C. O.
Iselin has pledged himself to contribute $40,000 toward the project,
providing the citizens of the town subscribe $60,000, and thereby
facilitate the erection of a modern building. Twenty thousand dollars
has already been collected.

The Pennsylvania State Board of Health has inaugurated a course
of instruction for persons suffering from or exposed to transmissible
diseases. The knowledge is dispensed by means of circulars, and com-
prises practices regarding the care of afflicted as well as precautions
calculated to insure prevention.

The Chicago Medical Society elected the following officers at its
annual meeting on June 20: President, Doctor George W. Webster;
secretary, Doctor Robert T. Gillmore; councilors, Doctors William A.
Evans, Charles S. Bacon, Frank Billings, Lewis L. McArthur, and
Farnand Henrotin; alternates, Doctors William E. Quine, Henry F.
Lewis, Winfield S. Harpole, Brown Pusey, and Theodore Tieken.

286 MEDICAL NEWS.

The Dental Alumni Association of the University of Pennsylvania
has erected a bronze tablet in Dental Hall to commemorate the late
Doctor Charles J. Essig, one of the country's foremost workers in the
dcHnain of dentistry, and professor of dental mechanics and metal-
lurgy in the Quaker institution.

The records of the California State Medical Society were lost in
the recent disaster. As a peculiar coincidence the society met in San
Francisco on April 17, 1906, the day before the catastrophe, and on the
morning of the i8th — in front of the ruined convention hall — ^the
meeting was declared adjourned.

German Southwest Africa is to be converted into a receiving
station for tuberculous Teutons. Evidently the sanatorium system as
conducted in Germany has not produced the most desiraUe results,
and since the climatic conditions in Germany's portion of the dark
continent are ideal for the consumptive, the government has decided
to test the plan by sending a number of afflicted working people to the
continent.

The hospital system of San Francisco suffered severely from the
recent earthquake, all but three or four being rendered useless. The
Children's Hospital was one of those which remained intact, and its
inmates are receiving the attention of Doctor Hezadiah Crabtree. A
Maternity Hospital has been established at Berkeley University, and
prospective mothers are thereby assured proper care during the
puerperium.

The Indiana State Medical Association held its annual meeting at
Winona Lake on May 23-25, 1906. Following are the officers elected
for the coming year: President, Doctor George J. Cook, of Indian-
apolfs ; vicepresidents, Doctor John B. Berteling, of South Bend, and
Doctor Charles J. Chittick, of Frankfort; secretary, Doctor Frederick
C. Heath, of Indianapolis ; treasurer, Doctor Albert E. Bulson, Jr., of
Fort Wayne.

The medical section of the Newberry Library, Chicago, has been
consolidated with the John Crerar Library of the same city. Together
with the library proper. Doctor Senn has given permission for the
transfer to the Crerar Library of the Senn Collection on Medical His-
tory. At present the quarters of the John Crerar Library are inade-
quate to accommodate the change, and a new building is being erected
as quickly as possible.

The New York State Commission in Lunacy will erect a State
Reception Hospital and Dispensary for the Insane. The Board of
Estimates and the Aldermen of New York City have authorized the
purchase of a piece of property 200 x 250 feet between Seventy-third
and Seventy-Fourth Streets, overlooking the East River, for the pur-
pose. The land will cost $146,000, and it will be leased to the state.
The Lunacy Commission will expend $300,000 in buildings.

MINOR INTELLIGENCE. 287

After a more or lesc successful career of twenty-three years, the
Ontario Medical College for Women has been discontinued, owing to
the establishment of coeducation in the Medical Department of Toronto
University. The attendance has been growing smaller each year, and
a disruption was the inevitable outcome.

One hundred two candidates received the degree of Doctor of
Medicine in Philadelphia on June 13, the event being the CMie hundred
fiftieth commencement of the University of Pennsylvania. The address
of the occasion was delivered by Professor John Bach McMaster, of
the history department of the University.

The thirtieth annual meeting of the American Dermatological Asso-
ciation was held in Qeveland, Ohio, May 31 and June i and 2, 1906.
The following officers were elected for the ensuing year: President,
Doctor Arthur Van Harlingen, of Philadelphia; vicepresident, Doctor
William A. Pusey, of Chicago; secretary-treasurer, I)octor Grover W.
Wende, of Buffalo. A number of excellent papers were read and dis-
cussed, among them being one by Doctor William F. Breakey, of the
University of Michigan.

The Chicago Medical Society has been considering the "contract
practice" question. A protest was raised by the Douglas Branch of this
organization, and the referendum showed that 358 members were
opposed to perpetuating the practice, while 201 were of the opinion that
the present system should continue in vogue. The total membership is
1,928, and inasmuch as the by-laws require that fifty per cent of the
members must engage in a referendum in order to insure its validity
the vote was far from being decisive.

That the conduct of confinement in case of triplets is not always
pecuniarily remunerative was demonstrated recently in New York
City. Some time ago a grocer in the Borough of Queens engaged the
services of a physician to deliver his wife. The stipulated fee was
eighteen dollars, but after discovering that the procedure contem-
plated dealing with triplets, the physician increased the charge to $50,
which the grocer refused to pay. Litigation ensued in the Jamaica
Municipal Court, and the jury decided against the plaintiff, notwith-
standing the fact that the case required the services of two extra
medical assistants.

Because of the utter disr^^rd which quacks and venders of nos-
trums evidenced for the law pertaining to the practice of medicine,
Judge Green, of New York City, has evolved the following clear and
simple definition : "The practice of medicine is the exercise or per-
formance of any act, by or through the use of any thing or matter, or
by things done, given, or applied, whether with or without the use of
drugs or medicine, and whether with or without fee therefor, by a
person holding himself or herself out as able to cure disease, with a
view to relieve, heal, or cure, and having for its object the prevention,
healing, remedying, cure, or alleviation of disease."

288 RECENT LITERATURE.

The San Francisco catastrophe rendered necessary the convening
of a special session of the California legislature, during the deliberations
of which enactments of interest to the medical profession were passed
which contemplate the following appropriations : The University of
California receives $83,800, about $8,500 of which is to restore buildings
and apparatus damaged in the Medical and Veterinary departments;
the Agnew State Insane Asylum, at San Jose, receives $25,000 for the
building of temporary quarters for inmates pending the erection of
permanent buildings ; the State Board of Examiners receives $2,500 for
the restoration of property; the State Board of Pharmacy receives
$2,500 for the restoration of property; amounts necessary for the
reproduction of the reeristers of the State Boards of Examiners in
Medicine, Pharmacy, and Dentistry; and amounts necessary for the
issuing of duplicate certificates to physicians, pharmacists, and dentists
who lost the original papers in the fire.

RECENT LITERATURE.

REVIEWS.

PROGRESSIVE MEDIQNE.*

Progressive Medicine for March, 1906, comprises the following
subjects: Surgery of the Head, Neck, and Thorax. Infectious Dis-
eases— Including Acute Rheumatism, Croupous Pneumonia, and
Influenza; the Diseases of Children; Rhinology, Laryngology, and
Otology. There is an index accompaniment. The abstracts are all well
done, and the compiler's personal opinion, which is frequently given, is
always of great value.

♦Lea Brothers & Company, Philadelphia and New York.

GALL-STONES AND THEIR SURGICAL TREATMENT.*

The first editiv>n, exhausted in eight months, tells the story of the
popularity of this work ; it pleases the pri>fession. Sufficient time has
elapsed since it first appeared for criticism and improvement. The
result has been a careful revision with added illustrations and explana-
tory cases, increasing the size of the book about seventy pages. The
illustrations are fine and the text is plain and well written. It is a good
boc4c and one is improved by reading it. Few books in medical lit-
erature merit such praise. c. c. d.

♦By G. A. Moynihan, M. S. (London), F. R. C. S., Senior Assistant
Surgeon to Leeds General Infirmary, Leeds, England. Second edition,
revised and enlarged. Octavo of 458 pages, beautifully illustrated.
Philadelphia and London. W. B. Saunders & Company, 1905. Cloth,
$5.00 net ; Half Morocco, $6.00 net.

A PROFESSIONAL MEDICAL JOURNAL.

VOLUME XXVIII. JULY, 1906. NUMBER VII.

ORIGINAL ARTICLES.

MEMOIRS.

RURAL CITY MILK SUPPLIES AND THEIR RELATION TO

INFANT FEEDING. HOME MODIFICATION VERSUS

LABORATORY MODIFICATION.*

ANNA MARION COOK, M. D.

AND

DAVID MURRAY COWIE, M. D.

[from the DBPARTUBNT of PBDIATRICS, university of MICHIGAN.]

Excepting the good that may come from frequent repetition of
already known facts, thus aiding the dissemination of the knowledge
of modern infant feeding, it would seem that there is little excuse for
an article having the above title. When, on the other hand, we compare
the analysis of milk made in various countries and various parts of
our own country, note the variety of results obtained, the analyses upon
which are based the many formulae that have been introduced in text-
books, and endeavor with failure to reproduce results vouched for
by standard methods of obtaining definite fat percentages for home
feeding, it would Seem that some value may be attached to any investi-
gation that will help to clear up some of these discrepancies.

RURAL CITY MILK SUPPLIES.

Towns of 10,000 to 20,000 population, proportionate to their size,
receive their milk from a radius of twenty, thirty, forty and often fifty
miles. As distance is time, and time and handling are bacterial growth,
it is not difficult to see how conditions that obtain in small towns are
superior to those in the larger cities. It is a well-known fact that the
so-called good creams of large cities are usually several days old.
Conditions are better with certified milk. Seldom in rural districts
is cream delivered over twenty-four hours old.

The writers are indebted to the Ann Arbor Board of Health for

*Read before the Section on Medicine at the Jackson meeting of the Michigan
State Medical Society.

290 ORIGINAL ARTICLES

supplying them with samples of milk from the various dairy farms
which supply the city, and we take this opportunity to thank Doctor
Wessinger, the health officer, for much useful information furnished
us at an expense of his valuable time. The milk was brought to the
milk laboratory in serial number. The name of the dairy was withheld.
It was collected by an officer at an unexpected time, of his own choos-
ing. Except where otherwise stated the milk was bottled at the dairy
and not taken from the tanks in the milk wagon.

TABLE A.

PER CENT

DAIRY

FAT IN

SPECIFIC

TOTAL

DAIRY

FAT IN

SPECIFIC

TOTAL

NO.

GRAVITY

ACIDITY

NO.

GRAVITY

ACIDITY

WHOLE MILK

4.1

1032

5.5

1030

4.2

1038

4.0

IO3I

4.1

1032

3.8

1032

4.0

1030

3.6

1030

3.3

IO3I

3.8

1032

4.2

1034

4.2

1032

3.6

1032

6.3

1026

3.8

1032

3.2

1034

4.0

1032

5.0

1030

3.0

1036

3.0

1032

4.8

1032

3.8

1032

4.0

1034

5.6

1032

4.0

1034

3.2

1034

5.2

1034

4.2

1032

3.6

1034

5.2

1032

3.6

1032

4.0

1034

3.2

1034

4.0

1032

4.2

1034

5.0

1032

3.2

1036

4.4

1034

4.4

«033

5.5

IO3I

3.8

1032

5.0

1032

25.5

4.8

1033

4.5

1032

5.2

103 1

4.5

1033

The analyses of this series has to do only with the per cent, of fat
in the whole milk, the specific gravity and the total acidity. We have
considered standard milk one which has four per cent, fat, a speciiit
gravity of 1028 to 1033, and a total acidity not higher than 25.^ The
results of the analyses are as shown in Table A. By reference to this
table it will be seen that of the forty-nine dairies examined the fat
percentage was four, or above four in twenty-five, and that in nine of
these it was five or above ; seven were between three and one-half and
four ; eight were below three and one-half, and two of these were three
per cent. One dairy furnished a ten per cent, milk, which was too high
for good milk and too low for good cream. It was reported as cream
below standard, and subsequently it was found that the high percentage
of fat was due to an attempt to deceive the Board of Health, which had
had trouble with this dairy before.

The specific gravity varied proportionately with the fat in most
cases. It is interesting to note that in the milk of herds in which the

RURAL CITY MILK SUPPLIES. 291

inspectx)r found mammary and udder disease, the total acidity was
high, always 28^ or above. Invariably when the acidity was much above
25 it could be traced to dirty stables, dirty cows, and careless milking
methods. The trouble has been in the stables and in the milker. It is
of very little avail that the housekeeper puts the milk in a cool place and
protects it from all contamination, if from the time it leaves the udder,
until it reaches the consumer, it has been through a course of dirt col-
lection from unclean hands, unclean pails, unclean tanks, et cetera.
This journey through unclean receptacles is too frequently evidenced
by the visible sediment that greets the eye as the bottom of the con-
tainer is reached.

We found through the investigation of the Board of Health, that
the usual plan of dispensing milk is as follows: All bottled milk is
taken from the previous evening's milking, and that which is not
bottled is carried in the faucet tank in the front compartment of the
wagon. All milk taken from the cows in the morning is put into ordi-
nary cans. It must be evident to every one that the bottled milk, even
though it is of the night milking, stands a better chance of reaching the
consumer in good condition than milk that is put in the faucet tank or
in ordinary cans. It must be a very difficult task to keep the tanks and
cans clean, even when the strictest measures of cleanliness are observed.
How great the chances of contamination when no special thought is
given to them ! Picture the bacteria that may lurk in the seams of the
can and the bottom where it is impossible to reach with hand and brush I

After counseling with the Board of Health we decided that for the
present, until more elaborate methods can be carried out to prove the
value of these simple methods, that standard milk must contain four
per cent, fat, and have an acidity not above 25 per cent, decinormal
sodium hydroxide solution. We have found that by notification and
instructions to the dair3mien that the high acid values in the milk have
been lowered. We find most of the milkmen anxious to cooperate as
best they can, and a visit to the various dairies in this district demon-
strated to us that much of the faulty condition was due to their lack
of knowledge of bacterial growth. The condition in the milk rooms
was for the most part fairly good, but in the stables no eflForts were put
forth to secure the cleanliness that is so essential. The amount of good
that can be accomplished by local boards of health cannot be overesti-
mated. When the public begin to realize that by far the greater num-
ber of deaths in infants and young children, rich and poor alike, are
due to diseases of the digestive organs, and that these are caused by
impure milk, greater efforts will be put forth to bring about conditions
that will compel dairymen to have regulation stables and produce
standard milk. If only common cleanliness could be guaranteed, thous-
ands of infants' lives* could be saved yearly. Sterilization will not
accomplish as much as is expected of it. Germs kill not only by invad-
ing the tissues of the body but also by elaborating chemical poisons in
the milk, which are unaflFected by either Pasteurization or sterilization.

292 ORIGINAL ARTICLES.

We must have clean milk. If health officers were better paid and were
obliged to qualify for office by competitive examination, before an
unbiased board, much of the difficulty would be solved.

Taking all things into consideration the above analyses show that
the milk supplied to Ann Arbor is on the whole good so far as its fat
content is concerned. Some of the dairies, particularly numbers one
and six, we have examined at various times for two or three years and
have never found the fat per cent, below four. They have frequently
been dirty, and at these times their acidities have been high. The
dairies around Ann Arbor represent the prevailing type. They are
probably no better and no worse than those in other districts. The
milk that is being delivered is physically good, is seldom skimmed or
diluted. LxDwered fat percentages can usually be traced to improper
and poor feeding, in but few instances to diluting.

MILK ANALYSIS.

Practical milk analysis resolves itself into the estimation of but a
few points. Without these no milk modification can be correct. The
possession of more minute data will help us but very little. Even
methods that are thought to be most ideal are only approximate. We
have, then, to estimate the per cent, of fat in the whole milk and in the
cream, the specific gravity, and if we would have the alkalinity correct,
the total acidity should be known. However, for practical purposes
this is not necessary, and the total acid value may be employed as a
means of gaining some idea of the cleanliness of the product used.

Fat estimation requires about ten minutes time. The most reliable
test is the Babcock test. Small hand-turning testers are manufactured
by various creamery manufacturing companies. A whole outfit can be
bought for a comparatively small sum, including directions which are
too familiar to you all to require repetition here. All fat estimations
reported in this paper were made with a large electric centrifuge.

The approximate percentage of proteids is estimated by comparison
of specific gravity with fat per cent. The proteids of milk are fairly
constant, more constant than the fat. They are estimated at four per
cent. If the specific gravity is low and the fat per cent, high, the pro-
teids are normal. If the fat per cent, is normal or high and the specific
gravity high, the proteids are increased. If the fat per cent, is normal
or low and the specific gravity is low, the per cent, of proteids is
decreased. It is more necessary to be in possession of definite percent-
ages of fat than of proteid. The symptoms of excess of proteid are much
more evident than are those of excess of fat. The stools may be used as
an index of proteid digestion, yet it must be remembered that infants
may thrive and manifest no complaints and still show curds in the
stools. This symptom alone does not necessarily mean that the casein
must be decreased. It must be combined with other phenomena which
go to make up the symptom complex of proteid indigestion.

Sugar in cow's milk for practical purposes may be considered as a
constant factor varying little from six per cent. The polariscopic

RURAL CITY MILK SUPPLIES. 293

method for sugar estimation is the most practical and is very accurate.

Knowing the percentage of fat in the whole nulk and in the cream,
it is a very simple matter to calculate the quantity necessary to give
the required amounts. We find Baner's^ method of great practical
value. It is simple and gives fairly accurate results. We think as
accurate results can be obtained by home modification with this method
as are usually obtained by Walker-Gordon Laboratories, and it is much
better from the standpoint of independence as there is no patent upon it.

Percentage feeding resolves itself into so simple an algebraic
expression that any one mathematically inclined can devise equations
of his own, if he cares to. Those who do not wish to spend time work-
ing out equations of their own can accept this method and have the
assurance that they will obtain good results. Possibly its only point
of failure is in the calculation of low proteid percentages, but this
applies only when low per cent, top milk fat is employed. The method
is as follows :

BANER'S METHOD.
Let Q represent the quantity of mixture required for twenty-four hours.
F represent the desired per cent, of fat.
P represent the desired per cent, of proteid.
S% represent the desired per cent, of sugar.
A represent the desired per cent, of limewater.

C = Cream, M = Milk, W = Water, LW = Limewater, S = Sugar.
It will be found that
Q

% of fat in cream — 4
QXP

X (F — P) = Cream in ounces.
— C = Milk in ounces.

X Q = Limewater in ounces.

100
Q — (C -f M + LW) = Water in ounces.

= Sugar in ounces.

(S% - P) X Q
100

Example: A mixture of forty-eight ounces containing three per
cent fat, one and five-tenths per cent, proteid, six per cent, sugar, and
five per cent, limewater is desired. The whole milk is known to con-
tain four per cent, fat, and the cream, upper four ounces, after standing
four hours, sixteen per cent. fat.

C = — z^ X (3 — 1.5) = 6 ounces.

16 — 4 ^ '

M = ^^ ^ ''^ — C =12 ounces.

LW = ^35- X Q =2.4 ounces.

W = 48 — (6 4- 12 4- 2.4) = 27.6 ounces.
S^(6-..S)X48

100

ORIGINAL ARTICLES.

These equations assume that the whole milk contains four per cent,
fat and four per cent proteid. In order to use the formulae with exact
results we must substitute the actual per cent, of fat in both cream and
whole milk. For instance, if milk tests 4.5 or five per cent fat the
cream will test about eighteen per cent, fat (Table D). After having
run a number of tests we are satisfied that most milk containing four
per cent, fat will not show greater than sixteen per cent, fat in Ae
upper four ounces of cream.

The following cases illustrate how near the desired amount of fat is
obtained by the equations. table B.

HOSPITAL MODI pic A TIONS,
BABY F.

LIME-

FAT PER CENT

FAT

SUGAR

PROTEID

DATE

QUAWTITY

PER CENT

WATER
PER CENT

IN
MODIFICATION

4-1-06

18 OZ

0.5

4-2-06

««

1-9

4-3-06

2.1

4-4-06

4-5-06

4-6-06

f«

1.6

4-7-06

2.2

4-8-06

4-9-06

2.1

4-10-06

«4

4-1 1-06

22.5 OZ.

4-12-06

<«

1 (whey)

4-13-06

Average 1.99

BABY McD.

5-8-06

48 OZ.

2.5

0.5

2.5

5-9-06

2.5

0.5

2.5

5-10-06

2.5

0.5

2.4
Averacre 2.46

BABY K.

5-8-06

18 OZ.

0.5

5-9-06

0.5

1.8

5-10-06

0.5

2.
Average 1.93

BABY A.

5-16-06

36 OZ.

0.5

5-19-06

48 OZ.

I.O

5-20-06

56 OZ.

I.O

2.6

5-21-06

1.0

2.8

5-24-06

•4

I.O

5-27-06

««

I.O

2.8

5-2&-06

I.O

2.6

5-29-06

I.O

3.0

HOME MODIFICATIONS,

5-1 1-06
5-1 1-06

Mrs. S.
Mrs. B.

2
2

6
6

0.5
I.O

5
5

2.
1.9

RURAL CITY MILK SUPPLIES.

296

An eighteen ounce mixture, of two per cent, fat, one-half per cent,
proteid, six per cent, sugar, five per cent, limewater was required. The
modification (Baby F) was made according to the equation given. The
modified milk was then tested for its fat per cent., with the result that
in thirteen days the average fat was 1.99 per cent. We could hardly
look for more accurate results than these. Our method of separating
the upper four ounces was one that every busy mother would probably
use. We simply poured oif the top milk or cream, our object being to
test a home method of modification that would be within the range of
ability of any household. We find that the percentage of fat by this
method does not diifer from that obtained by use of the siphon.

TABLE C.

PER CENT

PER CENT OF DISTANCE OF CREAM LEVEL FROM THE TOP TO THE

OF FAT

BOTTOM

OF A STANDARD QUART BOTTLE AFTER STANDING

NO.

IN
WHOLE

MILK

4 HOURS

5 HOURS

6 HOURS

7 HOURS

8 HOURS

4.2

33 0

4.5

33.3

4.2

35.0

4.8

34.8

5-0

4.6

34-3

4.6

36.3

3.9

31.2

3.7

28.1

6.2

39.1

5.0

40.6

4.2

32.3

33.0

4.2

29.7

5.1

36.0

5.0

37.5

4.9

28.1

4.8

34.4

5.0

40.6

The average cream depth of those milks approximating 4^ fat is a little less than
a third of the distance from the top to the bottom of the bottle. Those approximating
5% a little over a third of the distance (36.9% ).

The percentage of fat in the whole milk of herds will necessarily
vary with the conditions existing at different times of the year, and
while it is not necessary to make daily fat estimations they should be
made at more or less frequent intervals, particularly if the infant shows
signs of digestive derangement.

We have made a few observations on the depth of the cream layer,
after standing four hours (Table C), with relation to the fat content of
the whole milk. A regulation quart bottle, allowed to stand four hours,
after being thoroughly mixed, will show a more or less definite fat per
cent when the cream layer is a certain depth. When the depth was
thirty-three and one-third of the bottle depth the per cent, of the fat in
the whole milk averaged about four ; when the cream depth was thirty-
five to thirty-seven per cent, of the bottle depth, the fat per cent, aver-

296

ORIGINAL ARTICLES.

aged five. This, too, can be used with fairly accurate results in home
modification.

To vary the percentage of fat, it is necessary to use diflFerent layers
of the miyc. When the upper four ounces contain approximately six-
teen per cent, fat, the second four ounces will yield six per cent, fat, the
third four ounces four per cent, fat and the fourth four ounces three per
cent, fat, so that by simply pouring oflf the top in definite amounts
almost any desired per cent, of fat content may be obtained. By using
the upper eight, twelve or sixteen ounces, we may get fat per cents, of
approximately twelve, ten, and seven per cent., which are somewhat
lower than the percentages claimed by Holt.

TABLE D.

AFTER STANDING FOUR HOURS THE FAT PER CENT IN THE

EXPER.

FAT IN
WHOLE MILK

NUMBER

UPPER 4

SECOND 4

THIRD 4

FOURTH 4

OUNCES •

OUNCES

4.2

16.8

4-5

16.2

4-2

14.4

4.8

14.4

5.9

17.0

4-6

14.2

4.6 •

15.5

4.9

14.0

3.7

13.6

5.0

18.0

6.6

4.6

4.4

4.8

17.2

6.0

2.0

1.8

5.0

18.4

6.4

3.0

2.4

' 13

4.6

17.2

5.4

3.4

1.6

4.8

17.6

6.4

4.4

2.6

4.0

16.0

5.8

3.4

3.0

4.0

16.0

5.8

4.0

3-2

3.8

15.4

5.2

3.8

3.4

There are a good many reasons why gravity cream is better than
centrifugal cream, for milk modifications. There may be something in
the objection that in centrifugal cream the natural emulsion is par-
tially destroyed, but there is considerable diflFerence of opinion upon
this point. We think that the arguments in favor of gravity cream are
that it is usually fresher and the percentage of fat more constant than
in the centrifugal cream distributed in this section. If creams of
definite percentages were placed on the market, we can see that a great
advantage would be secured. There seems to be no eflFort in this direc-
tion in the smaller towns and unless the fat per cent, in cream is esti-
mated very frequently, disordered digestion will surely arise.

Our method of removing different layers of top milk after it has
stood a certain length of time, and thus procuring more or less definite
fat percentages, seems to us to be far more satisfactory. Holt and
others following in his lead, have given examples of top milk feeding
and have reported their results of analyses of the diflFerent layers of
top milk. We have repeated their experiments (Table D) and have

RURAL CITY MILK SUPPLIES. 297

been unable to produce the results obtained by them. Our conditions
were probably different. We sought to have them the same as in the
home, where the modifying is most often done. A milk that is set
immediately after milking will, after four hours, raise a higher per cent,
of fat in the cream than milk that has stood for a time, then mixed and
reset for four hours. The latter are the conditions that must neces-
sarily exist in the home, when milk is obtained from a milkman some
hours after milking, the time of the milking and the amount of jolting
unknown. It may be for this reason that our results differ from those
of other investigators. At no time were we able to obtain twenty per
cent, fat in the upper four ounces of a quart of milk. The highest we
encountered was eighteen and four-tenths per cent. Usually an aver-
age of sixteen per cent, was obtained. Even with five per cent, whole
milk twenty per cent, cream could not be obtained by four or six hours
setting.

From our investigations we can say that a milk, after being thor-
oughly mixed by pouring from one vessel to another and set in a stand-
ard quart bottle, will yield in the upper four ounces approximately
sixteen per cent, fat instead of twenty per cent., as is claimed by Holt
and others.

THE PROTEIDS OF COWS MILK.

The proteids of cow's milk differ from those of woman's milk in
that the percentage of casein is greater and that of soluble albumin less.
It is the casein that gives us the greatest trouble in infant feeding. It
was never intended that the human animal should consume large
amounts of casein. It would seem then that any method of milk modi-
fication that has as its object the elimination of excess of casein, must
be the most ideal. So far as we know the proteids that remain in cow's
miik after the casein has been removed, are identical with those of
woman's milk. They are at any rate soluble albumins and require much
less digestive work than do the insoluble or solid milk bodies. If, then,
. we wish to feed an infant soluble albumin, in quantities sufficient to
equal the proteid content of mother's milk, it is evident that the use of
whey alone which contains but 1.17 per cent, proteid will not accom-
plish this. To increase the content we should have to evaporate the
whey, that is, if we evaporate the water of twenty ounces until it is
reduced to ten ounces we will have a whey containing twice the amount
of proteid of the twenty ounces, or 2.34 per cent, proteid. This is
hardly practical for home modification because of increased timie
required in the preparation, which is in reality the only objection raised
by mothers against modified milk. During the first two months of
life is the time when an infant most needs soluble albumin or milk that
closely resembles mother's milk. We do not care to raise our proteid
content during this period above one per cent.

It would seem that our argument does not hold, when our constant
aim has been to modify the milk of the cow to as nearly a counterpart
of mother's milk as possible, for it is a well-known fact that throughout

296 ORIGINAL ARTICLES.

the lacteal period mother's milk never contains less than two per cent,
proteid. But we must bear in mind constantly that cow's milk can
nerer be exactly like mother's milk, and practical experience has dem-
onstrated to us that infants thrive on whey modifications and develop
bone.

Nothing definite has been worked out with regard to the exact modi-
fication of the salts. These are reduced by dilution as are the proteids.
Experiment has shown, however, that very little of the salts are lost in
the making of whey, so that by the use of whey in our modifications
instead of water as a diluent we increase rather than decrease our salt
per cent.

Qinical experience has taught us that infants fed on modified milk
do better proportionately as the amount of casein or solid food is gradu-
ally increased. It may be necessary to begin with simple whey, a
method that has proven very satisfactory, where the child is never
nursed by the mother. To feed an infant for any considerable length
of time on a purely soluble albumin diet or low casein diet might easily
lead to serious consequences.

To prepare soluble cUbumin or whey the casein is removed most
conveniently by the use of commercial junket 'tablet. One tablet dis-
solved in a little water, added to a quart of skimmed milk, which has
previously been heated to 98*" Fahrenheit will yield from thirteen to
fourteen ounces of whey in fifteen minutes time. The casein separates
as a greenish-yellow, semiopaque fluid. In separating the curds from
the whey pressure should be avoided. We found a single layer of
absorbent cotton worked rapidly and effectually as a filter.

The mother must be especially instructed in regard to the use of the
junket tablet as the directions on the box are not for making simple
whey. Trouble arises if squeezing is employed, as casein passes through
and the whey will have a milky look.

It must fce remembered that rennet works rapidly, and like other
ferments there is little limit to the duration of its action. It is still
actively present in the whey and if it comes in contact with the casein,
as the casein of the cream in a milk modification, it mil rapidly convert
it into curds. Hence the necessity of bringing the whey to a tempera-
ture of 150'' Fahrenheit before adding the cream. This requires but a
few moments time,

HOME MODIFICATION VEHSUS LABORATORY MODIFICATION.

We now come to the consideration of the accuracy of percentage
milk modifications, modifications produced at milk laboratories, and
those produced in the hospitals and in the home. We will consider
only fat percentages, as fat is the most variable constituent of cow's
milk, and the one that concerns us most in infant feeding. It is gener-
ally believed that percentage milk feeding and the term "modified milk"
originated with those who were the instigators of the laboratory idea.
It will be of interest to many of you to know that percentage feeding

RURAL CITY MILk SUPPLIES. 299

was not only worked out some time before the formation of the Walker-
Gordon Company, but the ideas were given to the profession in book
form by Doctor William Henry Cummings, of Williamstown, Mass-
achusetts, in 1859, in a little book entitled "Food for Babes; or, Arti-
ficial Human Milk and Manner of Preparing and Administering It to
Young Children." If any of you have access to this interesting little
work by Doctor Cummings and will turn to page 58, you will find that
he says : "The milk adapted for the newborn calf is not suitable for an
infant. It must be modified or else it will do harm rather than good."
He goes on to state that "there is too much cheese in cow's milk and
the child cannot digest it." He then accurately works out the yearly
needs of a child in pounds of butter, proteid and sugar, which he esti-
mates at twenty-five, seventeen, and ninety respectively for a year's
feeding for an average child. Then he proves the inadequacy of cow's
milk as a substitute, showing that in the same quantity of milk a child
would get but sixteen and one-half pounds of fat in a year's feeding,
but a great increase in the casein. He further gives specific dilutions
for various ages suiting the modification to the changes incident to
development in the child.

It is said that Liebig had it so arranged that his prescriptions for
infants' food, which consisted in the addition of maltose to cow's milk,
were filled at an ordinary pharmacy and that other physicians patron-
ized these places. Liebig's object was to bring about conditions that
exist in woman's milk. This is another evidence of the adage, "There
is nothing new under the sun," and would seem to detract from the
claim of the laboratory people that they were the originators of the
per<;entage method of feeding. However, as they have popularized
this method they are entitled to the honor that should come from its
general adoption.

Milk laboratories claim for their product accurate percentages and
clean milk. It is upon these claims that their success depends. There
has been some dissatisfaction with laboratory milk both on the part of
the profession and the laity. We think that Doctor Morse* is justified
when he says that "much of the criticism has come from physicians
who have failed to appreciate the purpose and capabilities of the labo-
ratory ; that some physicians seem to have found the laboratory a con-
venient scapegoat to account for the lack of development of certain
babies, fed on laboratory milk prepared according to their own direc-
tions." "It has been much easier and more condusive to their self-
respect to attribute the failure to the laboratories rather than to their
own imperfect methods of prescribing," and that "the laity are inclined
to exaggerate every mistake made by the laboratory and minimize their
own."

However, knowing much of the above to be true, we cannot help
being impressed with certain facts that confront us. We must stand
with those who give obeisance to the sentiment, "to the law and to the
testimony." Does the Walker-Gordon Company live up to its claims?

300

ORIGINAL ARTICLES.

By reference to Doctor Wentworth's* series of analyses of laboratory
milk modification (Table E), part of which we incorporate below, it
will be seen that frequently inaccurate products are dispensed. Out of
twenty-six different samples only two gave the percentage of fat pre-
scribed (numbers nine and sixteen). One gave one per cent, too little
fat (number twenty-two). In fifteen of those analyzed too little fat was
found, an error of one-half per cent, or more in each case. This
impresses us as a difference too great for a company making such
claims, especially as with but two exceptions the error was a lowering
of the fat content. These experiments were made four years ago, but

TABLE E.
ADAPTED FROM DOCTOR WENTWORTITS REPORT,

< a H
^ u z

FORMULA

< d H

-} bd 2

FORMULA

:3 Ctf M

3 « M

S M U

SUPPLIED

S M U

SUPPLIED.

Oi Q ^

« Q at

p fl« £

PER CENT.

0 otf u

PER CENT.

u, 0 £

to. 0 £

NO.

DATE

FAT.

NO.

DATE

FAT.

Dec

i8, 1901

4.2

Jan. 3, 1902

2.2

I9f 1901

3.5

2.5

" 7. 1902

2.6

19. 1901

2.6

" 9, 1902

20, 1901

3.5

" 15. 1902

2.4

20, 1 90 1

3-5

3.2

" 23, 1902

2.3

21, 1901

1.5

1.6

" 24. 1902

2.3

<«

21, 1901

3.6

" 27. 1902

3.3

23, 1901

3.5

2.8

" 29. 1902

1-3

24. 1901

3.5

Feb. 28, 1902

24, 1901

4.2

Mch. 7, 1902

25. 1901

3.4

" 15, 1902

3.1

26, 190 1

3.5

3.2

" 18, 1902

3.4

30, 1 90 1

3.4

*' 24, 1902

there ought not to be any reason to believe that conditions at the pres-
ent time are any better than they were then. The argument used
against the commercial baby foods is that they do not furnish proper
amounts of fat, and this series of analyses seems to show that the lab-
oratory milk is in reality little better.

The question naturally arises, Where is the fault? We have no
reason to think that the company's intentions are not good. In its
infancy, and of late years, it has delivered milk with exact prescribed
percentages. It is not at all improbable that success has brought to it,
as to many other prosperous business concerns, a feeling of self-secur-
ity, protected, too, by its patent, and consequently carelessness has crept
in, particularly on the part of the employees. One of us visited the prin-
cipal Walker-Gordon laboratory in Boston last summer, in company
with a lay friend. The laboratory is pictured as perfect in its appoint-
ments and immaculate in its cleanliness. What greeted the eye, how-
ever, was not even the cleanliness of a down-town butcher shop, nor
could we be impressed that it was sterilized uncleanliness. The man at

RURAL CITY MILK SUPPLIES. 301

the rack was juggling prescriptions, it seemed to us at the rate of fifty
per minute. Occasionally a little milk slopped over. It did not seem to
us that the care of a drugstore prescription clerk was g^ven to the com-
bining of the various constituents of the milk modifications. A visit,
the same day to the Floating Hospital showed an entirely different state
of affairs. There home modifications were being prepared by the phy-
sicians, nurses and mothers. Cleanliness was paramount, even though
their quarters were much crowded.

The Walker-Gordon Company had difficulty in obtaining a patent
on percentage milk modification. It is generally known that it was
owing to Doctor Rotch's influence that it was finally obtained. In a
letter presented to the patent office at Washington by the Walker-
Gordon Company, Doctor Rotch says : "It js of the greatest importance
to physicians that this process should be protected in every way as it
is a question of many babies' lives being saved by it in the future.
Unless protected and under careful supervision great harm may be
done by the misuse of this new instrument of precision which you have
placed in our hands and which the physicians of the future will surely
thank you for." Doctor Rotch, the instigator of the laboratory idea,
has no financial interest in the concern. He has simply been a zealous
promoter of what ought to be an ideal system, and has worked unsel-
fishly.

The patent was granted, a peculiar patent, which cut off competi-
tion, the most wholesome stimulant for the production of superior
articles. It is indeed fortunate that there can be no patent to prevent
one from carrying out similar operations in the home. Our experiments
with home modifications, by nurses and mothers, show that the results
obtained are generally more accurate than laboratory modifications, at
least so far as the fat content is concerned. The large bulk of the
population is scattered through the rural districts. They do not need
Walker-Gordon laboratories, but they must have clean and uninfected
milk. The medical profession and enlightened mothers can arrange the
rest ; patents are unnecessary. It would be hard to improve upon the
Walker-Gordon milk as it is received from their farms. The conditions
at the farms are said to be excellent. The cows are well chosen and
their feed carefully regulated. All the cows have been tested with the
tuberculin test. This is a great advantage over the ordinary herd milk
as delivered in towns. It is a question whether this high grade milk
may not more than compensate for the differences in the percentages
of the modified milk. There may be some good reasons for such a
patent but we fail to see the benefits to the public, to the babies, for
whose benefit the patent was granted. Other concerns of great magni-
tude have prospered, as the Mellin's Food Company, without patents
or copyrights. We think that the patent was unnecessary and has been
the means of retarding the furtherance of what might be a great boon
to bottle-fed babies if properly controlled.

The laboratory idea is a good one, but equally good if not better

302 ORIGINAL ARTICLES.

results will be obtained in the rural districts by intelligent home modi-
fication. It will doubtless be only a matter of a few years before the
state of Michigan, through the efforts of the State Society, which rep-
resents the professicHi of the state, will require that all cows used for
dairy purposes shall be proved to be free from tuberculous infection by
means of the tuberculin reaction. Under present conditions we think
that the dairymen are in a sense justified in objecting to the test. This
objection is of course purely commercial They cannot appreciate why
they should lose the value of a cow or part of a herd because a tuber-
culin reaction has been obtained. It would seem only just that the
state furnish cows of standard breeding to replace the diseased cows.
There is no other article of food that is more generally used than milk
and the various food products manufactured from milk.

There are very few infants that cannot be fed on modified cow's
milk if the principles of milk modification are thoroughly comprehended
by the physician. The question of the superiority of one sugar or one
alkali over another is a subject worthy of much attention, but for lack
of time cannot be discussed here.

^In the estimation of the total acidity no account was taken of the CO3 content.
The figures accordingly are only approximate.

'Baner: New York Medical Journal^ Volume LXVIl, 1898, page 345.
'Morse: Journal^ of the Michigan State Medical Society^ 1905.
*Wentworth: Boston Medical and Surgical Journal^ 1902.
A. M. C, Ntw England Hoi^itnl, Rtxhury, Matfckntettt,

D. M. C, Univtrtity 0/ Michigan, Ann Arbor,

LESSONS IN LONGEVITY.

JOHN S. CAULKINS, M. D.
SECOND PAPER,

The questions formulated in the opening paper on this subject
were:

Is it desirable to attain the age of eighty-three years?

If so, how is that objective point to be reached?

Only the first query was considered in that discussion. The second
will now receive attention.

The conclusion arrived at, with regard to the first point, was that
whether seen from the personal or sociologic side no generalization
could be made, circumstances varying so widely that every case would
have to stand on its own merits and be determined by its own surround-
ings. These are so different that no general rule can be applied. Every
very aged person is in a class by himself. One may find life desirable
until late into its evening, while his much younger neighbor may find it
intolerable.

Reference having been made in the former paper to Osier's grim
pleasantry about a deadline for all at sixty, the logical conclusion was
drawn that the practice would not apply as a general rule, since much,
or at least some, good work has been done by older heads and hands

LESSONS IN LONGEVITY. 303

than are contemplated by the three-score mark, and its adoption would
consequently reduce working years down to twenty, Osier's dictum
being that a man is physically ripe at twenty, mentally at thirty, and
morally (if ever) at forty, leaving, after being ripened all around, only
twenty years for work. Since the product of the fully ripened man is
all that is really and truly valuable, everything else being deficient and
immature, the time limit is too short for finishing anything calculated
to benefit mankind in the way of upward development. Give us forty
years for study and work instead of twenty and one after another the
evils that now infest human society will disappear. They are all caused
by ignorance. They are disease, crime, poverty, war, and every other
noxious thing that can be named as the result of ignorance, or you
may call it imperfect knowledge. What is wanted is study — ^more time
for study to learn their causes and. how to avoid and remedy them. We
are thus led to the conclusion that if we cannot affirm longevity to be
a blessing in each individual case we can affirm it in the general case :
that the way to improve mankind is to lengthen the span of human
life. The conviction cannot be resisted that herein lies Ae remedy for
the evils which beset us from the cradle to the grave. More time is
wanted — ^more time to investigate the causes of these evils and more
time to study their remedies. There is no alternative, and the fact always
has been more or less imperfectly felt. This is why poets and prophets
in all ages have inculcated reverence for old age. They clearly saw
that it was the old upon whom the young must depend for help.
Examples of filial piety have consequently been with them a favorite
theme, like Eneas carrying oflf his father from burning Troy on his
. shoulders. "Honor thy father and mother," says the decalogue, "that
thy days may be long in the land that the Lord thy God giveth thee."
There is involved in this injunction much more than a mere sentiment
of respect for progenitors. It involves doing as well as feeling — doing
all that can be done for the comfort and well-being of the aged,
thereby prolonging their time and the opportunity to work for the
good of coming generations.

The field for this work is wide, we might say interminable, and
needs age as well as youth for its exploitation. When the end of the
path, as now known, is reached, it is for youthful vigor and enthusiasm
to push on and find new paths, but youth cannot give undivided atten-
tion to work alone, it must stop and sow its wild oats and wait for the
crop to be harvested before knowing the value of its own discoveries.
Time is needed and the serenity of mind that age alone can bring, to
separate the true in them from the apparently true and to digest and
assimilate the new truth. When Osier said that the world would miss
very little of real value if his sixty-year limit were enforced, his bolt
flew widely from the mark. To show how widely, let us mention a
few names out of the long list of the old who have done work that
the world would miss, beginning with our own country and time.

Doctor Oliver Wendell Holmes. — Not claiming that what was

304 ORIGINAL ARTICLES.

done by Holmes belongs to the highest class of work, it is safe to say
that it is the best of the class to which it belongs, and who would like
to miss that delightful compound of fun, wit, and wisdom that he has
left us. Ask William Osier this question and we may be sure he will
say — **Not I for one. Here is really an exception to my general rule."
We must remember that Holmes was past eighty when he wrote his
last book, or as he himself put it, he was "eighty years young."

Doctor Willard Parker is another name to be mentioned among
our contemporaries. He was born in 1800 and died in 1884. Like
Holmes, he was active to the last — b, famous surgeon, original in
methods, skillful in practice, a fluent writer and a good teacher. He
was a philanthropist, too, and, for several of his later years, president
of the New York State Home for Inebriates. His observations and
discoveries in surgery are of lasting and real value, and the world
would have missed something if he had died twenty-four years sooner.

The above are two names out of a long list that could be made
from among our contemporaries who have worked hard after they had
passed the four-score stake, but time will not permit. However, we
will mention another.

RussKLL Sage, the old New York banker and millionaire, is now
eighty-seven past and as sharp in chasing the dollar as the youngest
in the race. Whether he will be missed is a problem. Likely he will,
hut whether his confreres will view his departure with pleasure or
regret we are unable to say.

Joseph Henry died in 1878 in his eighty-second year, being secre-
tary and director of the Smithsonian Institute, president of the Amer-
ican Academy of Sciences and of the Philosophical Society, director
of the Coast Survey, and in the actual discharge of all his duties
until the very last, besides carrying on his own original researches in
physics which place him in the front rank of the great physicists of the
world.

Edward Everett Hale is conspicuous among our old who are still
alive. He is the author of "The Man Without a Country," a book very
much read and admired forty years ago. His latest book, "Recollec-
tions of One Hundred Years," shows no decline in mental vigor. It
is a chatty and very readable discussion of the events of the last cen-
tury, as good as any of the more than forty books of which he is the
author, but leaning rather too much to suit me towards the federal
side of our early politics. He is at present chaplain to the United
States Senate. He is one month younger than the man who is reading
to you.

Thomas W. Higginson, another Massachusetts scholar and author
of a great many books, is a year younnger than Hale, and is as busy
and active. His present incumbency is historian for the State of
Massachusetts.

Francis Parkman, another Boston scholar and author, did not
reach the advanced age attained by his neighbors above, his life span

LESSONS IN LONGEVITY. 305

having been broken when it reached a little beyond the three-score-and-
ten mark. He was a sickly man, with very poor eyes, but in spite of
these physical handicaps his work is of more permanent importance
than that of any of the above-mentioned, and he and his work can be
quoted in proof of the assertion which will be made further on, that
good, hard work, if pursued with lofty motives and love of the work,
improves rather than impairs the prospect for long life. Parkman's
work is the history of the long struggle of the French (finally ending
with the fall of Quebec in 1759) to colonize North America. The
work is so exhaustive and its style so fascinating that there is nothing
left for another historian to do. It is safe enough to pronounce its
twelve volumes to be monumental literature.

Before taking leave of our contemporaries, let us mention the
names of three famous women who were very old, and who retained
their mental equilibrium to the last. These are Lucretia Mott,
Elizabeth Cady Stanton, and Susan B. Anthony. They were
reformers, lecturers, and writers, very prominent in the antislavery
agitation. Mrs. Mott was much older than the other two, and died
about 1880, at the age of eighty-eight years. Mrs. Stanton died
recently at the same age. Miss Anthony was still with us at eighty-six
in the discharge of her official duties at the New York State Industrial
Home for Inebriates, having received her appointment from Governor
Flower. It was mainly owing to her exertions that the law was passed
exempting the woman's earnings from liability for the husband's debts.
A notable incident in her career is her experience as a voter. She
believed that the fourteenth and fifteenth amendments gave women the
right to vote, and she accordingly went every year to election and offered
her ballot. To get rid of her the board finally concluded to take the
ballot and then prosecute her for the offense of illegal voting. This
was done and she was fined one hundred dollars, but no effort was ever
made to collect the fine.

There was a fourth woman, more famous in her day than the
others. She belonged to a family noted for genius and longevity, both
of which are conspicuous in her hereditary endowment since she
reached the age of eighty-four, and gave to literature a long list of
books, the second of which has been translated into many foreign
languages. This woman is Harriet Beecher Stowe. Those whose
memory cannot revert to the time have but a faint idea of the sensation
caused by the appearance of "Uncle Tom's Cabin" and the great part
this book played in bringing about the abolition of American slavery.
Mrs. Stowe is referred to here in a spirit of fairness, since the claim
is not advanced that the old do all the good work, or that all the work
they do is good. Her history counts on the other side; she outlived
her usefulness twenty years and gradually lost her memory. The
charitably inclined will plead her mental failure as an excuse for her
two books attacking the characters of Lord Byron and his sister,
charging them with the abominable crime of incest.

306 ORIGINAL ARTICLES.

Let US now glance backward at the careers of some of the illus-
trious dead who have made our country great, and have done g^ood
work late in their evening of life.

Benjamin Franklin, philosopher, statesman, and patriot, was
seventy when he signed the Declaration of Independence; seventy-two
when he made the treaty with France which sent Lafayette and his
soldiers to aid Washington in capturing Cornwallis and his army at
Yorktown, thus securing our independence of Eng^land and giving us
the opportunity to develop into the great country we now are. When
he signed the final treaty of peace with England he was seventy-eight.
He lived six years longer, very much troubled with gout, but with
clear and unclouded intellect. It is a reasonable conjecture that Frank-
lin might have lived many years longer except for the onerous duties
which the ambassadorship imposed on him, depriving him of the fresh
air and exercise to which he had always been accustomed. The Con-
tinental Congress was too poor to hire clerks for him. He was obliged
to do his own drudgery and was greatly overworked. Having been all
his life very temperate in eating and a consumer of large quantities of
water, it is very likely that the wines and high living that French polite-
ness heaped on him helped the gout to break down his natural hardy
constitution.

John Adams, second president (1796 to 1800), after retiring from
the presidency was entrusted by his native state with important matters,
among them being, when he was eighty-five years old, the drafting of
a new constitution for Massachusetts.

Thomas Jefferson, third president (1800 to 1808), effected the
Louisiana purchase from Napoleon Bonaparte, together with the terri-
tories from the Mississippi to the Pacific Ocean. This famous achieve-
ment laid the foundation for the present greatness of our country.
After retiring he founded the University of Virginia and for several
years was its presiding officer. He died in 1826, on the fourth of
July. John Adams died the same date, just fifty years after the signing
of the Declaration of Independence.

John Quincy Adams, sixth president (1824 to 1828), retired at
sixty-two, and after that represented his state in congress nineteen
years, as long as he lived. His diary, in a number of volumes, is a
record to the day he fell from his seat in the house. It is valuable as
historic material. He was eighty-one years old and as bright as at
any period of his life.

Albert Gallatin (1760 to i848),statesman, diplomat and scholar,
of first rank. He was minister to France for seven years. Returning
from that country when he was seventy-two years of age, he was then
sent to England on the same mission. On his return from London
he retired from public affairs and devoted the remainder of his life
to the study of Indian ethnology. He was a leader in this branch of
science and consequently an authority. His interest in public as well

LESSONS IN LONGEVITY. 807

as his own private affairs was unabated until the last. He died at
eighty-eight, showing no signs of mental atrophy.

This list of old working men of our country could be indefinitely
extended, but to prevent this paper from being too long we will cease
the enumeration here to make room for reference to some old men in
other countries.

William E. Gladstone, the grand old man of Britain, premier for
the fifth time at eighty-five. It is almost incredible that so old a man
could have the vigor, mental or physical, to transact so much business
as the care of the whole British Empire involves.

Isaac Newton (1642- 1727), physicist and mathematician, is
another illustrious example of mentality retained in extreme old age.
He was seventy-four when he solved a problem, proposed by Leibnitz,
his celebrated German rival, which was puzzling the mathematicians of
Europe. When he died, at the age of eighty-five years, he was presi-
dent of the Royal Society.

The three Herschels, astronomers, all lived to be old and retained
unclouded minds. That sublime genius, the elder Herschel, the dis-
coverer of the eighth planet of the solar system, reached eighty-five,
and the youngest attained nearly the same age.

Caroline Herschel, the sister and aunt, lived to be much older —
ninety-eight. She was given a medal by the Ro)ral Society for astro-
nomical work pursued when she was seventy-eight, and was made an
honorary member of the society, as was also another woman who lived
a long life devoted to science.

Mary Somerville was the author of many books of permanent
value. Her great work on "Physical Geography," an exhaustive book
in two volumes, from which all later writers draw their materials, was
not finished until late in life. Her health remained good and she
retained an unimpaired mind until the last. . She died at the age of
ninety-two, in her sleep.

Before canvassing the rest of Europe for instances of prolonged
activity let us revert again to the American continent and see what
our sister republics of Mexico and Canada can add to our list. Here
is a brief sketch of three Canadians and one Mexican.

Sir J. W. Dawson, the Canadian geologist, if still alive is eighty-
six. All geologists recognize the value of his numerous books and
fossil discoveries, among the most important of which is that of the
eozoon canadense, so far as yet known, the oldest form of animal life
that appeared on our planet. He was born in 1820, and began to write
and publish books in 1847. The first venture was "The Old Red Sand-
stones of Nova Scotia," and the practice of bookmaking has been per-
severed in until recently, a book appearing every year or two. In 1893
he published two— "Salient Points in the Science of the Earth," and
the "Canadian Ice Age." It was a favorite theme with Dawson to try
to read geological truth into the first chapter of Genesis. His latest
books are as good as his first.

308 ORIGINAL ARTICLES.

Daniel Wilson was not, like Dawson, a native of Canada. He
was Scotch by birth and already eminent as an archaeologist before
leaving Scotland. At about twenty-seven he came to Toronto and
accepted a professorship in the University, where he remained until his
demise. He was a prolific writer of books, some of which, like the
"Missing Link," were on the wrong side of the question, but his educa-
tional work has seldom been excelled in value and was not impaired
by age, which did not quite reach the four-score mark.

Goldwin Smith, perhaps the most illustrious of the trio, is still
alive at eighty-three. He is English-born and had achieved prom-
inence before coming to America, having been Regius Professor of
History for ten years at Oxford, and author of many books of English
history and biography. After reaching our shore he was for three
years Professor of History at Cornell, then, in 1871, he accepted
the editorship of a paper at Toronto, where he has since lived. He was
fifty-one years old at the time of his elevation to the editorial tripod.
Since then he has written many valuable books, his forte being history.
His last work of that kind dates back only nine years. During our
civil war Goldwin Smith was the solid friend of the Union, and his
writings had an immense influence in holding England steadily neutral
and preventing her from giving active aid to the Confederacy. Smith
is an original thinker and a brilliant writer. His luminous and
expressive style makes it a pleasure to read anything he writes. Besides
being a historian he is a scholar, linguist, and translator of the old
poets — Greek and Latin, and a critic of the first rank. His last volume
of translations of the Greek tragedies appeared .twelve years ago. How
long his activity will hold out no one can divine, but there is no sign of
senility present as yet.

PoRFiRio Diaz, the president of Mexico, is now seventy-six years
old. All that the country now is it owes to this able and enlightened
man who, from the scene of chronic and chaotic revolution has
changed it to a prosperous and progressive republic, respected by the
rest of the world. Every well-wisher of the human race must hope
to see his term of activity last many years more.

Turning to France, we find many examples of long, active life, of
which we will quote a few.

BuFFON, zoologist, lived to eighty-one.

Voltaire, lived to eighty-four.

FoNTENELLE (1657-17S7) Hved to OTit hundred. He wrote many
books in both prose and poetry on music, drama and romance, most of
which are now forgotten, although famous in their day. He is the
greatest French humorist and much of his wit is yet extant. His dis-
position to joke persisted to the very last. As he lay on his death bed
just before he drew his last breath, his friends standing around to see
him die, another friend whom he had not seen for a long time came in
to pay his last respects. Fontenelle faintly recognized his friend and
this little dialogue followed :

LESSONS IN LONGEVITY. 309

Friend: Est que vous souffrez?

Fontenelle: Non j'n souffre pas, de tout.

Friend: Ne souffrez pas! Pourquoi etes vous au lit?

Fontenelle: C'est une certaine, petite difficulte.

Friend: Une difficulte! Quelle difficulte?

Fontenelle: C'est une difficulte d'etre.

With a faint smile on his lips Fontenelle shut his eyes and the next
moment was gone.

Coming to Germany, we find so many names of scholars who have
left us work of permanent value done after reaching the four-score
mark that it seems invidious to select among them. We will mention
a few.

ScHLOSSER ( 1 775-1861), historian, finished his "Weltgeschichte"
(History of the World) five years before he died. After that he wrote
his last book, "The Critic of Dante." His industry as a writer was
remarkable and liis last books were not inferior to the rest.

Alexander Von Humboldt (1769-1859), scientist, naturalist,
explorer, lecturer and author, finished the last volume of his greatest
work, "The Cosmos," during the last year of his life.

Wolfgang Von Goethe (1749-1832), the immortal, called by his
contemporaries the all-sided. Goethe is the greatest of German poets
and the greatest German student of nature. Saying nothing of his
poetry, his botanical researches, some of which were made after he was
past eighty, will assure him a place among the revelators of the secrets
of nature and a fame that will endure as long as civilization itself.

Italy, the land of song and of great deeds since the first dawn of
history, has her full share of famous old men, of whom a few will be
named.

Louis Cornaro (1467- 1 566), a Venetian nobleman, was rather
wild in his youth, and at forty had so impaired his health by his riotous
living and self-indulgence that a fit of sickness overtook him which
threatened to be fatal. However, he recovered by the narrowest margin
and lived the rest of his ninety-nine years in a sober, temperate, and
cheerful manner. At the age of eighty-three he wrote his first book,
"A Sure and Certain Method of Attaining a Long and Healthful Life."
At eighty-eight, ninety-one, and ninety-five he wrote books on the
same subject. The main point in his "Sure and Certain Method" was
temperance in eating. He subsisted during the latter part of his life
on one tgg 3. day.

Michaelangelo (1475-1564), architect, painter, sculptor, and
poet, and master in all four professions. Among his greatest works
at Rome are the Sixtine Chapel and Saint Peter's Cathedral. He died
before he had finished the latter, on which, at eighty-nine, he was still
at work. He was never married, but after he was past sixty he fell
violently in love with Vittoria CoUonna. As she was young and beau-
tiful and he old and very homely he said nothing about it to her, but
took it all out in writing sonnets to her that are aflame with sentiments

810 ORIGINAL ARTICLES.

of love and friendship. He called it Platonic love, but it was probably
the genuine article. In the fighting line Italy has produced the oldest
successful general and the oldest successful admiral that history records.

Enrico Dandolo (1110-1205) was eighty-three when he was
elected doge of Venice. He had been doge ten years when he laid siege
to Constantinople and took it, to seat a claimant, Alexius, on the impe-
rial throne. The next year he started on a crusade with a French army
to capture the Holy Sepulchre from the infidels, but getting as far as
Constantinople and learning that the city was in possession of the
opposite party, who had murdered Alexius, he abandoned his crusade,
laid siege to the city and took it a second time, by storm, pillaged it,
and made Count Baldwin, of Flanders, emperor. What adds to our
wonder is that Dandolo was blind.

Andrea Doria (1468-1560) was doge of Genoa and one of the
greatest sea fighters that history mentions. His main business was
fighting the Turks, who at that time were threatening to overrun
Europe. He restored the independence of his own country by driving
out the army of the French king, Francis I, and was oflfered its sover-
eignty but refused, preferring to be a citizen. Like Washington, he
was called the Father of his Country.

Examination of the remaining countries of Europe might aflFord
equally as good material as that already cited, but this paper is long
enough now, although one name in Spain ought to be mentioned.

Cervantes, the author of a book — "Don Quixote" — ^which has
probably caused more mirth than any other book ever written. He
did not reach so great an age as some, but he was a man who had
endured all kinds of hardships, having been a common soldier and a
slave among the Algerines. It is sufficient to say that he wrote the
last half of that book after he had past the three-score years and ten.

Two famous Russians will be noticed in concluding.

Count Lyof Tolstoi (bom 1828), reformer, author and advocate
of human rights. Suspected by the Russian government and excom-
municated by the Russian Church, he is yet as busy as ever with his
pen in the good cause.

Metschnikoff (1845), the other famous Russian, has just reached
Osier's deadline. He is still at the Pasteur Institute in Paris coralling
the phagocytes, and endeavoring to subject them to order for the pur-
pose of studying their habits and thereby discovering how to prevent the
dry rot of old age. He has already made some wonderful discoveries,
rendering certain things plain that have long been a puzzle. He lives
strictly in accordance with his own discoveries and theories, and eats
his curdled milk every day for his regular diet to colonize his intes-
tinal canal with its bacteria, one of his most practical discoveries
being that the microbes of sour milk are the most deadly enemies of
the bacteria of putrefaction, which are always swarming in the intestinal
canal ready to riot whenever opportunity presents. What MetschnikoflF
does in this line henceforth will be watched by the world with great

NECROSIS OF THE MASTOID PROCESS. 311

interest. He has said lately that the problem of producing something
practical for the prolongation of life does not seem to present insuper-
able difficulty.

The above notices of the work of some old folks could be increased
indefinitely by including the yet active workers in their eighth decade,
but enough has been said to show the nullity of Osier's disparaging
estimate of the value to the world of the old, and we may express the
hope that he will live to prove it by his own example in his new sphere
of activity.

This subject will be resumed in a paper giving the ideas, observa-
tions, and theories of the writer on the second proposed question — How
to be alive and stirring when eighty-four years have passed over one's
head.

NECROSIS OF THE MASTOID PROCESS.

WALTER J. BENN, M. D.

A LABORER, aged forty-two, was brought to me, December i, by his
brother and sister, who complained that their brother had "something
the matter with his head." When asked to describe his symptoms, they
said that he had "acted queer" for about two weeks ; did not seem to
be interested in his surroundings; was listless and spent his time in
sitting in absolute idleness; constantly complained of pain and a
"funny feeling" in his head, and was "getting worse."

History. — In early childhood, patient was troubled with frequent
attacks of earache, and occasional discharge from right ear. At the
age of six, an attack of acute mastoiditis — at which time he "nearly
died" — resulted in the breaking down of the bony structure sufficient
to allow pus to escape at a point about three-quarters of an inch pos-
terior to the attachment of the concha and about the middle of the
mastoid, this being followed by a speedy apparent recovery. Since
this first attack, patient has had five similar, though less severe, attacks
at varied intervals, the last having occurred about "two years ago."
Patient's general health has been comparatively good. I was unable
to obtain family history except that two sisters and two brothers are
healthy.

Examination. — Pulse, 83 ; temperature, 99^ ; face vacant and
expressionless; pupils, dilated; watch-tick, at orifice of right external
auditory meatus, nil ; on right mastoid, nil ; at left orifice, faint ; on left
mastoid, distinct; on frontal, faint. It was necessary to speak very
loudly to make patient hear, and he watched my lips to aid him in
understanding what I said. Right meatal walls swollen, orifice one-
eighth inch in diameter; left meatal walls swollen, orifice about one-
quarter inch in diameter ; left meatus full of fresh pus which had dried
around orifice. There is a cicatrix, one inch long, over right mastoid,
extending obliquely from a point one-half inch posterior to base of
suprameatal triangle, downward and backward to a point three-quarters

312 ORIGINAL ARTICLES.

of an inch posterior to inferior border of concha. This scar is from
one-eighth to one-quarter inch wide, and skin is adherent Pressure
on either tragus and on right mastoid caused vertigo, and nausea fol-
lowed pressure on left tragus. No pain on pressure of either mastoid.
Right middle and inferior turbinated bodies hypertrophied posteriorly,
typical chronic condition; left turbinates slightly hypertrophied; septal
spur five-sixteenths inch wide, one-eighth inch thick, extending the
whole length of septum horizontally, about one-eighth inch above floor
of left nasal fossa; slight ozena in anterior area of left nasal fossa;
slight ozena in anterior area of left nasal fossa. Posterior walls of
pharynx hyperemic and covered with white catarrhal exudation ; fauces
congested; tonsils slightly enlarged. After irrigating with hot water,
swelling subsided sufficiently to admit speculum, and I found right
tympanum externum and ossicles absent ; inferior posterior two-thirds
of left tympanum externum absent, the free border of the remaining
third smooth and crescentic.

Diagnosis, — Chronic mastoiditis, suspicion of necrosis, right side;
chronic suppurative otitis media, left side.

Trcahnent. — I recommended complete mastoid operation as the only
means of curing the condition on right side, but neither patient nor
his friends would consent to this. I did not feel that I could obtain
satisfactory results in any other way, but agreed to attempt a cure by
medication alone. I instructed patient to irrigate the meati four times,
at intervals of two hours, with water as warm as could be borne, and
to return the following day.

On December 2, 1905, I irrigated meati with warm boracic acid
solution, and discovered right posterior meatal wall to be soft and of a
brown color. With a cotton-tipped applicator, I broke through this
wall, and disclosed a large sequestrum, the odor from which was very
offensive. After removing about a drachm of necrosed tissue, I found
that the applicator entered both the antrum and the tip of the mastoid,
the intercellular structure having necrosed and left a cavity between
the superior, anterior and inferior meatal walls and the external plate
of the mastoi(^ This cavity I filled with boracic acid solution, and with
the cotton-tipped proble I removed what I could of the necrosed tissue.
I then had the patient turn his head to the left and filled the cavity
with a one to one thousand solution of alphozone, allowing this to
remain in the cavity twenty minutes. I then dried the diseased surface
and packed cavity with moist, five per cent iodosyl gauze. This line
of treatment was followed, daily, for a month, and at each sitting I
sprayed the nasal fossae with alkaline solution and nebulized with
camphomenthol compound in abolene, with very little change in con-
dition except that there was a brighter appearance of the face and a
more comfortable feeling on the part of the patient.

On January 2, 1906, I removed the septal spur. After the first
month, I added to the treatment a second irrigation consisting of a
solution — two grains to the ounce — of potassium permanganate, which

GASTRIC SURGERY. 313

I forced through the Eustachian tube, with Politzer bag, from without
inward, and discontinued the alphozone. At the close of the third
month no more necrosed tissue followed either the irrigation or the
probing, and I then discontinued the iodosyl gauze packing, the alkaline
spray and the nebulization.

Since April i treatment has been as follows: Warm water irriga-
tion; glycothymoline (full strength) dropped into cavity; alcohol
dropped into cavity (each application of liquid being forced through the
Eustachian tube and the cavity thoroughly dried after each application) ;
insufflation with powder ccwnposed of twenty parts camphor and eighty
parts boracic acid ; a final Politzerization and a loose packing with cot-
ton. Treatment every second day from April i to June i. On June
4, patient went to work in the shipyard, and was instructed to call
Wednesdays and Saturdays, and, on June ii, I obtained the last sign
of pus.

As this article treats of necrosis of the mastoid, I have purposely
omitted treatment of the left ear, and will only say that I followed a
similar line of treatment to that indicated for the right ear.

In conclusion, I, will say that the patient continues his work at the
shipyard ; is cheerful and comfortable ; hears and understands an ordi-
nary conversation at a distance of two feet without watching the lips ;
claims to hear the watch-tick against right meatal orifice and can hear
it, distinctly, at a distance of fourteen inches from the left ear. The
left tympanum externum has reformed with the exception of a central
perforation the size of a small pinhead. I am continuing the treatment
twice a week, with slight modification, although I consider the patient
practically discharged.

Bay City, Michigan,

ORIGINAL ABSTRACTS.

SURGERY.

FRANK BANGHART WALKER, Ph. B., M. D.
rRonosoK of surgbrt and opbrativs surgbry in tmb obtroit postgraduatb school of mbdicinb;

ADJUNCT PROPBSSOR OP OPBRATIVB SURGBRY IN THB DBTROIT COLLBGB OP MBDICINB.

AND

CYRENUS GARRITT DARLING, M. D.

CLINICAL PROPBSSOR OP SURGBRY IN THB UNIVKRSITY OP MICHIGAN.

THE PRESENT STATUS OF GASTRIC SURGERY WITH

SPECIAL REFERENCE TO THE TREATMENT OF

CHRONIC ULCER.

Louis Frank, M. D., of Louisville, Kentucky, in American Journal
of the Medical Sciences for June, 1906.

The first portion of the paper deals with the historic part of gastric
surgery. The oldest operation on the stomach for the extraction of
foreign bodies was performed by Crolius, in 1602, to remove a knife.

314 ORIGINAL ABSTRACTS.

Though this was successful only thirteen cases had been reported to
1887. The first gastrostpmy, unsuccessful, was done in 1839, by
Sedillot. Pylorectomy was first performed by Pean, in 1879. The
first gastroenterostomy was f)erformed by Wolfler, in 1881. This was
done to procure rest for the stomach. The entire removal of the
stomach, which was first successfully performed by Schlatter, since
then by Bernays, Richardson, and a few others, is so rardy done that
we may dismiss it from our consideration of chrqEic ulcer.

In the treatment of cancer of the stomach we are concerned with
the proposition. Is the disease removable, and, if not, can anything be
done to prolong the patient's life, or relieve the starvation and pain
caused by obstruction? This condition, if left alone, has but one
ending and that is fatal. While having profound respect for laboratory
findings, he does not believe it best always to wait until all clinical
suspicions have been confirmed by these methods. Many patients
would submit to an operation if it were not for the fact that the family
physician often counsels against the advice of the surgeon, thus in
many instances causing a fatal delay. Cancer, no matter where located,
should always be removed upon the slightest suspicion, and the mere
fact that a tumor is present does not prove that it is beyond removal.

Chronic gastric ulcer, in the opinion of many, should be treated by
gastroenterostomy. He lays special stress upon the advice of Deaver,
who recommends gastroenterostomy for complications and sequelae of
gastric ulcer; in fact, in all diseases of the stomach where gastric
contents are not evacuated.

It is understood that the principal dangers of gastric ulcer are
hemorrhage and perforation. The direct treatment of hemorrhage
by excision of the ulcer, or direct treatment of the bleeding point when
it is possible, leads only to good results. Gastroenterostomy has given
the same results in the author's cases. Others have reported deaths
from hemorrhage following gastroenterostomy.

Perforation is liable to occur in the mildest case of gastric ulcer.
The symptoms of perforation are well known. There is only one
course to pursue after the perforation has taken place. The operation
of choice in ulcer is a properly performed gastroenterostomy. The
mortality of this operation does not exceed fifteen per cent. Symp-
toms of ulcer are always well defined. Pain indicates a relatively
advanced progress of the disease. Vomiting and nausea may be con-
sidered of only corroboratory value. Periodic attacks of headache are
frequently coincident with gastric trouble. His picture of a victim is
so vividly drawn that it should be given in full: "There are few
beings so abjectly miserable as those who are the victims of intractable
dyspepsia. The meal-time, which should be a delight, is a time of
despair and foreboding. The keen relish of good food, which the
man in physical health should appreciate, is a joy unknown or long
forgotten to the dyspeptic. A patient who has misery written in every
wrinkle of a thin, haggard face; who by reason of long suflFering and

MEDIAN LONGITUDINAl, INCISION. 316

bitter experience has felt compelled to abandon first one dish and then
another, until only fluids alone can be taken, and these not always with
impunity; a patient, to say the truth, whose life becomes embittered
by the pangs of a suffering which he must inflict upon himself, — ^this
patient will find, if a gastroenterostomy be done for the chronic ulcer,
which is the source of all his trouble, that his return to health and
appetite is at first almost beyond belief."

The paper closes with a respectful consideration of the gastric
analyst, whose opinions should be tolerated, but accepted only when
they fit in with clinical facts. When in doubt, use the exploratory
incision. c. G. d.

GYNECOLOGY.

REUBEN PETERSON, A. B..M.D.

PROPBSOR OF GTKBCOLOGT AND OBSTBTUCS IN THB UNIVBRSITT OF MICHIGAN.

AND

CHRISTOPHER GREGG PARNALL, A. B.. M. D.

PORMBRLT FIRST ASSISTANT IN CTNBCOLOGT AMD OaSTBTRXCS IN THB UNITSRSITr OF MICHIGAN.

SHORTENING OF THE ROUND LIGAMENTS WITHIN THE
INGUINAL CANALS, THROUGH A SINGLE SUPRA-
PUBIC TRANSVERSE OR MEDIAN LONGITU-
DINAL INCISION.

Peterson (Surgery, Gynecology, and Obstetrics, Volume III, Num-
ber I) describes an operation used in the gynecologic clinic of the Uni-
versity of Michigan Hospital during the last year. For the correction
of retyodisplacements of the uterus the author had found Alexander's
method the most satisfactory, when conditions permitted its utilization.
However, the Alexander operation is limited in application to cases of
nonadherent uteri, two incisions are necessary, and additional intrapel-
vic work is not usually feasable on account of technical difficulties
arising from the location of the incisions.

In order to retain the principle of the Alexander operation, and at
the same time to overcome its disadvantages, the writer has introduced
a new method of shortening the round ligaments. A transverse incision
is made down to the fascia just above a line joining the two pubic
spines. The upper edge of the incision is retraced upward and the fascia
exposed for two inches or more. The fascia is incised longitudi-
nally in the median line, the rectus fibres separated, and the trans-
versalis fascia and peritoneum opened high up to avoid the bladder.
Adhesions of the uterus and adnexa may now be broken up and any
other intrapelvic procedure can be carried out with ease. One angle of
the incision is then retraced downwards and outwards, and the fascia
cleared by blunt dissection over the external ring which is always
located at the base of the pubic spine. The canal is opened on a
grooved director, nerve filaments isolated and drawn aside, and the

316 ORIGINAL ABSTRACTS.

round ligament sought for just inside and below the edge of the inter-
nal oblique muscle. The peritoneum is now stripped back for several
inches. The opposite side is treated in the same manner. Both liga-
ments are drawn up while a finger inserted through the peritoneal
incision holds the uterus well up and forward so that the cervix points
downwards and backwards in its normal direction. The ligaments are
now seized by hemostats at the level of the internal rings to indicate
the amount of shortening necessary. The nerve is released and
the ligament secured to the under surface of the fascia by a modified
mattress suture of catgut. The edges of the fascia are united by a
continuous suture. After closing the inguinal canals the median
incision is closed by tier sutures of catgut. Care should be taken in
approximating the superficial fat that all dead space is obliterated by
appropriate sutures. The skin incision is closed as the operator desires.
No drainage is necessary.

The above principle of shortening the ligaments through a single
incision can be applied with the usual median longitudinal incision,
which is preferred when extensive abdominal work is necessary.

JackioHt Michigun. C. G. P.

OBSTETRICS.

WILLIAM HORACE MORLEV, Ph.B., M.D.

DBMONSTRATOR OF OBSTSTItlCS AMD CYNBCOLOGY IM THE UmVBRSITY OP MICHIGAN.

AND

WALES MELVIN SIGNOR, M.D.

FIRST ASSISTAKT IN OBSTBTRICS AND GYNBCOU>GY IN THB UNIVBRSITY OF MICHIGAN.

"ANESTHESIA IN THE FIRST STAGE OF LABOR."

Newell {Surgery, Gynecology, and Obstetrics, July, 1906), under
this title, advances the idea that the older beliefs with regard to the
time at which the anesthetic should be given in conducting a labor are
not applicable to the present status of civilization. As an excuse for
the use of ether or other anesthetic in the first stage, he maintains that
the modern method of life has removed women irom the normal stand-
ard, and hence makes of every case of confinement one requiring the
special attention advised for all abnormal labors.

As a result of racial progress womankind is less able to stand the
pain incident to the labor, and is entitled to relief as soon in the labor
as the pain becomes severe. This prevents a shattering of the nervous
system by the strain and makes the woman more willing to undergo
a second conception. He states that a majority of his series of cases
have been terminated by the application of low forceps. "This has
not been due to the effect of the ether on labor pains, but to my own
personal belief that the nervous and physical exhaustion entailed by
a more or less severe second stage will do more permanent harm than
a carefully performed operative delivery."

In support of his views he holds that the labor is not prolonged ;

RADIANT ENERGY. 317

that there is no apparent increase in the tendency to postpartum hemor-
rhage; and that the infant mortality is not necessarily increased. In
regard to the last point, he says that a deep etherization is often present
in the child requiring careful resuscitation. He believes that the spasm
of the cervical muscle is lessened and the dilatation of the cervix
hastened by the use of anesthetic.

A further portion of his article deals with the use of scopolamin
and morphin for similar anesthetic purpose in obstetric work. In this
he points out the dangers of the drugs and that further experience may
be advisable before they be taken into general use. In conclusion he
gives comparisons between the different forms of anesthetization as he
has met them in his work. w. M. s.

PEDIATRICS.

ARTHUR DAVID HOLMES, C. M., M. D.

HYDROCEPHALUS AND RACHITIS TREATED BY
RADIANT ENERGY.

Doctor Margaret Cleaves (Archives of Pediatrics, February,
1906) says: "Judging from the patholggy of hydrocephalus that the
X'TSlj which is able to penetrate so deeply as to outline not only the
bony structures, but internal organs, tuberculous lesions, thstt produces
disturbances of the cellular equilibrium of the blood, that is destructive
of germ life, and that can atrophy the Graffian follicles, can with per-
fect reason be expected to penetrate the cranial bones and act upon
the thickened granular ^endothelium and to promote and stimulate
nutritive changes."

The author reports two cases, one of congenital internal hydro-
cephalus, and one which had been four times diagnosed as primary
hydrocephalus and in which a rachitic element was recognized. In
both cases good results were secured. Doctor Cleaves said that her
paper was not presented with the thought that in radiant energy is to
be found a panacea for hydrocephalus and rachitis, but to call the
attention of the profession to the results obtained in the cases reported
that the way may open for further investigation of the subject.

Treatment should be instituted upon the first manifestation of
disease, even immediately after birth in congenital hydrocephalus, but
it should be administered with a full knowledge of the physics, physio-
logic action and therapeutic technique of radiant energy, superimposed
upon a knowledge of the pathology underlying the condition.

COMPLICATIONS OF SCARLET FEVER.

Hunter writes (British Medical Journal, February 24, 1906) that

in addition to the specific symptoms of this disease some cases present

rigors and diarrhea, while a few have pains in the limbs and others

epistaxis. The rash appears (in his series of one hundred fifty cases)

318 ORIGINAL ABSTRACTS.

in half the cases on the seccmd day, and in eighty per cent on the
first three days of the illness. The rash lasted five days in more than
half the cases. Desquamation began usually at the root of the neck
and in most cases within the first week. The complications are set
down as follows: Adenitis, nineteen per cent; albuminuria, of two
or more days' standing, twenty-one per cent; actual nephritis, 2.8 per
cent ; otorrhea and otitis, 6.4 per cent ; rhinitis and rhinorrhea, 64 per
cent ; rheumatism, 4.3 per cent ; secondary tonsillitis, 3.5 per cent We
also find mastoiditis, meningitis, optic neuritis and ocular paralyses
coming on after some cases of this disease. On the whole, a severe
rash is more likely to be followed by complications than is a mild one.
There seems to be no definite relation between the height of the
temperature and the occurrence of complications. The severity of
the disease and the septic complications of it are largely influenced
by the degree of oral sepsis in the patient when the disease commences.
Of cases without oral sepsis only thirty-five per cent had complications
of moderate or severe degree, whereas of cases with oral sepsis sixty-
five per cent developed such complications. Our first duty is, there-
fore, in every case to get rid of this great danger, oral sepsis, as far
as possible.

PREVENTION OF TUBERCULOSIS AMONG SCHOOL

CHILDREN.

Doctor Vautier, of Paris, in a paper in the Revue d' Hygiene et de
Medicine Infantiles, Paris, 1905, Volume IV, pages 691 and 723, has
reached the following conclusions: In the common schools of Paris
tubercular contagion appears to us to be very rare. This contagion may
be produced in a family during the school age, but even that is not
frequent. The number of children of school age, who have clearly
pulmonary tuberculosis is very small. Children, in a great majority of
cases, at least among the poor, are infected by latent tuberculosis at
the time of their entrance into school. He therefore proposes the fol-
lowing rules and regulations :

(i) Add to the instructions given relative to the construction of
school buildings, a rule favoring facing the building so that the sun's
rays may penetrate the class rooms and court.

(2) Replace wooden floors by those without joints in schools to
be built, and, if possible, in those already built.

(3) Exclude children who have evident tuberculosis, except that
surgical tuberculosis may be so protected by air-tight dressing as to
be safe.

(4) Send away members of the teaching force who have evidences
of tuberculosis, or put them in places where they will not come in con-
tact with children.

(5) Have schoolrooms thoroughly cleaned.

OBSERVATIONS* ON BROKEN NECKS. 319

(6) Seek to increase the strength of children by walks and games
for which open lawns are necessary. Fortifications or the space about
them are all that is necessary.

(7) Insist that the schoolmasters advise cleanliness and if need be,
require it, and that they make it possible for children to know the
meaning of a bath.

(8) Insist on obtaining from the boards of health, proper aeration
and size for homes and disinfection of places occupied by bacillus-
bearing tuberculous patients, especially at the time between the depar-
ture of the infected family and the entrance of another family.

(9) Invite the school boards to consider the matters of better food
for the children, furnishing a meal to many of them and making
arrangements for free medicines, especially those prescribed by the
attending physician.

(10) Send children convalescent from acute sicknesses, especially
those likely to become tuberculous: measles, pertussis, et cetera, to
special institutions in the country.

(11) Establish seashore hospitals at convenient places, where tuber-
culous children may stay six months or a year, and receive suitable
treatment.

ORTHOPEDICS.

IRA DEAN LOREE, M.D.

PIKST ASSISTAKT IN SUKGBRT IN THB UNIVBKSITY OP MICHIGAN.

OBSERVATIONS ON BROKEN NECKS.

Reginald H. Sayre, M. D., of New York {American Journal of
Orthopedic Surgery for April, 1906), first corrects the deformity and
after placing his patient in the Sayre position retains it by means of a
plaster-of -Paris jacket and helmet. Immobilization may be obtained
by extension to the head while liquid plaster-of-Paris is poured about
the head and neck or supported by sandbags.

Paralysis often recurs, hence it is necessary to keep the parts at
rest for a longer period than in an ordinary fracture. He does not
state any required length of time (no doubt it differs in individual cases),
but it is generally necessary to support the parts by means of a jury-
mast or other like apparatus after the patient is allowed to be up.

He has had in his practice eleven cases with results as follows : In
four there was a complete cure. Two had muscular control but there
remained some stiffness. One patient required support to the head;
however, he had good control of all muscles. Two remained para-
lyzed in the lower extremities. One died soon after injury and one
was under treatment at time of his report. In those cases where
complete readjustment is secured he expects a perfect cure. If paraly-
sis persists after manipulation he advises laminectomy.

320 ORIGINAL ABSTRACTS.

LARYNGOLOGY.

WILLIS SIDNEY ANDERSON, M. D.

ASSISTANT TO THE CHAIR OF LARYNGOLOGY IN THE DETROIT COLLEGE OF MEDICINE.

THREE CASES OF ETHMOFRONTAL SINUSITIS WITH

SPONTANEOUS EVACUATION THROUGH THE

ORBITAL REGION.

Saint-Clair Thompson (Revue Hebdomadaire de Laryngologie,
d'Otologie et de Rhinologie, June 30, 1906) calls attention to the com-
parative rarity of sinusitis opening into the orbit.

The first case reported was that of a woman aged eighteen, who
had an abscess at the level of the left eye following influenza. The
symptoms were those of ethmoid, frontal and maxillary sinus suppura-
tion. Incision and evacuation of the pus cured the patient without
further operation.

The second case was that of a boy, aged eleven, who had an abscess
of the frontal sinus following a cold. An incision was made, and pus
evacuated containing the micrococcus catarrhalis in pure culture. The
sinus was drained through the anterior wall and cure resulted. There
was no pus found in the nose.

The third case was that of a woman, aged twenty-five, who had
chronic sinusitis with acute frontoethmoidal exacerbations. The exter-
nal abscess was incised, a fistula remaining. Two months later an
operation demonstrated that the fistula led to an anterior ethmofrontal
cell. Several operations were necessary befqre a complete cure resulted.

The author compares these cases with abscess in the mastoid region.
If the infection is recent, then incision is sufficient as in the first case.
More severe cases require incision and drainage as in the second, while
severe cases require radical operative treatment, as in the third. Trans-
illumination was of value in the first case, where only one side was
involved. The absence of fever and general symptoms were charac-
teristic of these cases.

PROCTOLOGY.

LOUIS JACOB HIRSCHMAN. M. D.

CLINICAL PROVBSSOR OF PROCTOLOGY IN THB DBTROXT COLLBGR OF MBOICINR.

THE OFFICE TREATMENT OF INTERNAL HEMORRHOIDS

BY OPERATION.

•

In the March, 1906, number of The Therapeutic Gazette, Tuttle
states that the operative treatment of hemorrhoids in office practice
resolves itself into excision with suturing of the edges, or ligature with
or without transfixion. He discards the cautery on account of the
radiation of heat beyond the anesthetized area. The ligature is the
easiest, quickest and most satisfactory in the majority of cases. He

MULTIPLE SCLEROSIS. 321

describes his technique thusly: After the parts are thoroughly steril-
ized, he injects twenty or thirty minims of a half per cent solution of
cocain into the region of the lesser sphincterian nerve on either side
of the posterior commissure. After waiting three minutes a duckbill
speculum is introduced into the anus, and with this held firmly at the
anterior commissure, the sphincter is massaged with the finger for five
minutes, until it becomes loose and placid. Care should be taken to
avoid traumatism to the mucous membrane. After dilatation is accom-
plished, the hemorrhoids are caught one by one and injected with a
one-tenth per cent solution of cocain, and dissected up until a narrow
pedicle is formed well within the rectum. If the blood-vessels are
large, he transfixes with a double-threaded needle and ties on either
side, otherwise a single ligature around the mass suffices. The tumor
is then cut off below the ligature. After all the hemorrhoids have
been removed, he applies adrenalin solution to prevent subsequent
oozing, and the patient is allowed to go after a few minutes rest. The
operation may be modified by suturing the edges of the mucous mem-
brane, but Tuttle sees no advantage over the ligature, and he rarely
employs it.

NEUROLOGY.

DAVID INGLIS, M. D.

PROFBSSOR OP NBRVOUS AND MENTAL DISXASBS IN THB DBTROIT COLLBGB OF MROICINB.

AND

IRWIN HOFFMAN NEFF, M. D.

ASSISTANT PHYSICIAN AT THB BASTBRN MICHIGAN ASYLUM.

MULTIPLE SCLEROSIS: A CONTRIBUTION TO ITS CLIN-*
ICAL COURSE AND PATHOLOGICAL ANATOMY.

Taylor again states (Journal of Nervous and Mental Diseases,
June, 1906) the now well-recognized fact that multiple sclerosis is
more common, especially in this country, than we have formerly sup-
posed. He gives a resume of the reports on this disease, and also
reports twelve cases illustrating some of the difficulties of diagnosis
and exemplifying the necessity of a thorough consideration of every
case before the diagnosis of multiple sclerosis is excluded. Separate
paragraphs are devoted to the frequency, diagnosis, prognosis, and
pathological anatomy of the disease. Taylor believes that the diag-
nosis of multiple sclerosis is often absolutely impossible to make with
assurance during life, even in advanced stages of the disease. He
furthermore says that it is likewise possible that the diagnosis made
relatively early in the disease may give place to another as the process
extends. The writer also inclines to the view that the etiol(^;y of the
disease is still obscure and ventures the supposition of a selective poison
acting through the blood-vessels. Our chief interest, he says, still
centers, as it has in many years past, in the pathologic anatomy of the
condition, and in this field much interesting and important work has

322 ORIGINAL ABSTRACTS.

been done, with an alteration of opinion regarding the character of
pathologic process. The article is a valuable edition to this supposedly
rare disease and an extensive bibliography appended enhance the value
of the paper.

The general conclusions given by Taylor are as follows:
(i) The rarity of the disease in this country has been overesti-
mated. A more careful examination of atypical cases and a more open
mind in diagnosis is desirable.

(2) The importance of observing and properly estimating minor
symptoms of the disease, particularly unexplained spasticity and ocular
disorders, must be emphasized.

(3) The etiology remains obscure. The pathological anatomy is
still a hopeful field for study. Present evidence points towards a pri-
mary destruction of the myeline with either a secondary or coincident
proliferation of the neuroglia. i. h. n.

ITHE ADVISABILITY OF ELIMINATING THE TERMS
MENIERE'S DISEASE AND MENIERE'S SYMP-
TOMS FROM OTOLOGIC NOMENCLATURE."

Emil Amberg (American Journal of the Medical Sciences, July,
1906). Amberg's article is made up largely of excerpts from contrib-
utors to this disease. The concluding paragraph quite well expresses
the author's opinion of the symptom complex, and is as follows :

"We do not speak nowadays of heart disease or of heart symptoms,
of lung disease or of lung symptoms, nor of kidney disease or of kid-
ney symptoms. We are expected to diagnose and name a recognizable
affection of these organs more definitely, and if this is impossible, in
some instances, we leave the question open with the understanding that
further investigation is required to clear up some dark points. The
same rule, I think, should be followed in otitis interna."

The author furthermore believes that the "Meniere's symptom" can
be produced: (i) Through influences from the external and middle
ear; (2) through diseases of the labyrinth; (3) through diseases of
the brain and of the acoustic nerve; and (4) through neurosis, for
example, of the sympathicus (angioneurosis).

The author's conclusions are as follows:

( 1 ) The triad — hardness of hearing, vertigo, and tinnitus — is given
as constituting the functional disturbance observed in the so-called
Meniere's disease.

(2) These symptoms occur also in numerous affections which are
not based on the pathologic finding as described by Meniere in his
historic case.

(3) The observation that not always a typical picture is present has
led to the introduction of other terms, such as "Meniere's symptoms,"
et cetera, which has proved to be confusing.

(4) Even affections of the middle ear, of the outer ear, or of other

SPECIFIC FOR SEASICKNESS. 323

parts of the body can cause the symptoms described by Meniere.

(5) These latter causes can be diagnosed in many instances and
prove the existence of a great group of affections characterized by
functional disturbances of the inner ear.

(6) By abandoning the terms "Meniere's disease" and "Meniere's
symptoms" a more definite nomenclature can be introduced. This is
important not only from a physiologic and patholc^ic, but also from
a clinical standpoint. By using, for instance, the terms "otitis interna
syphilitica," or "leukemica," or "angioneurotica," or "gastrica" a clear
conception of some affections would ensue.

(7) The various terms should be agreed upon. The many inter-
national medical meetings give ample opportunity for such a procedure.

I. H. N.

THERAPEUTICS.

DELOS LEONARD PARKER, Ph. B., Hi. D.

LBCTURSR ON MATBRIA MBDICA IN THB DETROIT COLLBGB OP MBDICINB.

ATROPIN AND STRYCHNIN COMBINED, A SPECIFIC FOR

SEASICKNESS.

Brigadier-General Alfred C. Girard, United States Army,
retired (Jama, June 23, 1906), in a paper presented to the Inter-
national Medical Congress held at Lisbon in April of this year, sets
forth his ideas, which he has held since 1888, concerning the value of
atropin and strychnin in seasickness. At the outset, Doctor Girard
says:

"For many years I had believed that I was the original discoverer
of this treatment, but it seems that other physicians have used it at
times independent of my investigations, and I, therefore, do not pretend
to absolute originality, but I believe this report represents the views
of many observers working subject to my instructions under various
circumstances, and more than any individual views will establish the
value of the treatment."

The treatment consists of hypodermic injection of atropin sulphate
grains 1/120 (0.0005 milligrams) with strychnin sulphate grains 1/60
(o.ooi milligrams). This should be administered at the beginning of
a voyage, or when the sea begins to be rough, or at the advent of a
storm when the motion of the water causes nausea. In persons not
readily affected by belladonna the dose may have to be repeated once
or twice at hourly intervals. The signs for stopping further use of
the drugs are dryness of the throat and disturbances of vision. Prac-
tically always, however, the seasickness is corrected, if not before, at
least by the time incipient S3miptoms of the effects of the belladonna
are made to appear.

The advantages claimed for hypodermic medication in this disease
are the rapidity and certainty with which effects are produced, and

324 EDITORIAL COMMENT.

the control it gives over the amount of drugs actually taken up by the
circulation. Medication by mouth is uncertain, not only as to retention
by the stomach, but also as to absorption by the blood even when
retained.

As a rule a single dose is sufficient for a voyage, but on long trips
or trips beset with severe weather the medication may have to be
repeated.

'The rationale of the treatment may be found in the stimulating
effect of the atropin on the circulation in the brain, while the strychnin
causes a similar action through the spinal cord in the respiration."

Doctor Girard says that from his own experience and observation,
and from the reports of medical officers that have made use of the
treatment, he is satisfied the remedy is a specific. He concludes his
paper with a long list of letters and reports from medical officers
serving on army transports and on other ships, and the tone of these
reports shows that actual experience with the remedy has converted
them all into believers in its efficacy.

EDITORIAL COMMENT.

DISCORD AMONG DOCTORS.

Indications of dissatisfaction are quite apparent in various sections
of the country regarding the management of the American Medical
Association, and in certain sections the reaction has been so intense
as to force expression in effort to establish independent organizations.
It would be absurd to deny that some cause for provocation exists. It
would likewise be absurd to decry a laudable movement because affairs
are not managed in accordance with individual idea. Organizations
are generally conducted for the benefit of the majority, and no very
substantial reason obtains to prove the American Medical Association an
exception to the rule, notwithstanding a feeling prevails that the
national guild is being manipulated by a selfish minority. However
this may be, grievance has certainly been incited, as is evidenced by
complaint from every point of the compass, as well as by contention in
several quarters for secession from the parent body and inauguration
of an entirely new regime.

* 4e *

Michigan has recently declared for "quality" in contradistinction to
"quantity." The pronouncement emanates from Grand Rapids doctors,
and proposes a State Society wherein "the advancement of the science
of medicine and surgery will be the paramount purpose." The insti-
gators of the scheme advocate allegiance to the Code of Ethics adopted
by the American Medical Association in 1847, and disclaim, in the
following terms, intention to antagonize existing organization : ^ "We

DISCORD AMONG DOCTORS. 325

do not advocate the refounding of^a body whose function it shall be to
antagonize the present societies, except, of course, insofar as member-
ship in it would require nonaffiliation with any and all of them. If We
advocate an ethical society in the interest of scientific medicine and
surgery, not of politics and commercialism, and one, moreover, to which
we may belong with credit to ourselves, and to which we may point
with pride and affection, f What we propose, therefore, is not of the
nature of a secession from the present state body, but a reentering
upon the historical path from which it so radically diverged in 1902."

* 3k 4e

The restriction of membership to quality naturally raises the ques-
tion of standard for this prerequisite. A limitation of similar import
has been declared through the Southern medical press, the only excep-
tion being that Dixie exclusiveness contemplates cutaneous pigment
rather than cerebral possibility. The Michigan State Medical Society
certainly experienced a long siege of numerical limitation, and, as
regards quality of membership, the moral, medical, and mental stand-
ard averaged no higher than since reorganization became vogue. A
great deal of discussion might be advanced along this line, but an
article in a recent issue of the Lancet-Clinic regarding the exclusive-
ness of scientific societies in general contains a few sentences which
seem especially applicable to this particular instance, and hence editorial
prerogative is relinquished to contemporaneous expression : If "Medical
societies should he organized solely for the advancement of science and
the love of truth, and they should stand with outstretched arms to
welcome all who are willing to receive and ready to impart information
and knowledge. If Societies which are unnecessarily exclusive are
necessarily narrow, prejudiced and bigoted, and their work will even-
tually partake of the same character. If Additions to the societies are
dominated by the same influences, and new members are qualified by
personal rather than scientific attainments. ^ These societies, like all
organizations in general, are made up of the good, bad and indifferent,
and the close affiliation and exclusion impart to mediocrity a false,
fictitious value and an intolerable air of self-satisfaction. ^ Their
weakness is readily apparent, and their undoing is a matter of easy

accomplishment."

* * *

Georgia is reported to be engaged in forming an Independent State
Medical Society, and a G^nfederacy of Southern Medical Associations is
suggested by a Southern medical journal. In fact a movement which
points in that direction has already been inaugurated by the Arkansas
State Medical Society, which lately appointed a committee to formulate
plans for the establishment of a guild to be known as the Southwestern
States Medical Association, and composed of the present State
Medical Societies of Arkansas, Kansas, Missouri, Oklahoma, and Texas,
the procedure foreboding eventual secession from the American Medical
Association.

326 EDITORIAL COMMENT.

The foregoing are some straws that indicate which way the wind is
blowing, and it behooves the trustees and councilors to take cognizance
of belligerent possibilities before the stage is reached where forbearance
will cease to be a virtue. On the other hand, physicians should bear
in mind that Rome was not built in a day. Time is required to perfect
medical organization, and due allowance should be made for rodks and
shoals encountered along the coast. The organization movement is
indeed commendable and deserves hearty support, but the fact that
four years of arduous work has brought only about four per cent of
the profession into the fold seems to have created the impression that
possibly an entire change of policy is the desideratum essential to
insure wholesome success.

ANNOTATIONS.

THE UBIQUITY OF CELL UNDERSTANDING.

Baugh, of Canada, has offered some unique speculations on the
origin of the human mind, tracing the development of cell intelligence
from the ovum and spermatozoon to the fully matured comprehension.
That these generative units possess cell intelligence is manifested by
their inevitable union, the struggle for supremacy between the count-
less spermatozoa, and the final entrance of the victor into the female
cell. The development of mind is evidenced by the evolution of cell
understanding into the immature child brain, and eventually into the
complex adult mentality. The prenatal mind is influenced by trans-
mitted impressions through the mother, and the organism only bec(»ncs
conscious. of its being at birth, when, free from maternal influence, it
delineates its own course. All cells are endowed with the faculty of
choice, and their motility does not give rise to cell understanding, the
reverse being true. The most minute particle of animate material pos-
sesses the power of generation, and also the faculty of producing a
complex organism. The same intelligence which is apparent in animal
cells is likewise manifest in plants, flowers and fruit, the phenomenon
of cell intelligence therefore being ubiquitous.

MALARIA ASCRIBED TO ANKYLOSTOMA DUODENALE.

While the dissemination of malaria has almost universally been
ascribed to the pestiferous mosquito, the recent labors of Doctor Sehr-
wald, a Brazilian physician, with the Ankylostoma Duodenale, or hook-
worm, seems to emphasize the contention of certain authorities as to
the prevalence of other methods of conveyance. In a number of cases
of malaria under his observation, the investigator found the hookworm
lodged in the intestinal tract of the victim. Serial sections of the para-
site indicated that the malarial organisms wander from the intestine of

PHYSICIANS AND PHILOSOPHERS. 327

the worm into the mouth. The secretion of a peculiar fluid by the
hookworm prevents the coagulation of its host's blood at the point to
which it is attached, and that the transmission of the malaria parasite
from the mouth of the worm directly into the blood of the person can
readily be accomplished, is easy of conception. While no observations
have been made with regard to transmission of the disease from person
to person, by means of the eggs or larvae of the hookworm, the inves-
tigator ventures the assumption that infection may occur in this way.
Submitting that the theory of the Brazilian physician is correct, the
deduction ensues that the application of quinine for the relief of malarial
patients is of no avail so long as the parasite, the new etiologic factor in
the disease, retains lodgement. The investigations of Sehrwald seem
to indicate that persons who had suffered from malaria to the degree
of becoming anemic and debilitated, were restored to perfect health
after the elimination of the ankylostoma duodenale.

A WORD TO THE WISE.

The enthusiasm incident to successful organization has caused
some State Medical Societies to arrogate greater authority than can be
either advantageously or conveniently exercised. The bulletins estab-
lished to promote organization have sadly neglected proper function
and exceeded rightful scope, ostensibly for the purpose of coralling
every medical paper in sight and thereby forcing independent journalism
from the field. In certain quarters, however, the folly of striving to
conduct general journals has been realized, as for instance in Missouri
— where people have to be shown — ^and the following change was
recently instituted: "The association journal is to be hereafter more
completely devoted to organization ^and unifying the association ; it is
not to be the organ of any county society, and will serve the best
interests of each and all. Doctor Edward J. Goodwin, of Saint Louis,
will be its managing editor, a choice which assures conservative and
wise conduct for a valuable organ."

CONTEMPORARY.

PHYSICIANS AND PHILOSOPHERS.

[PROFBSSOR CHARLBS WILLIAM SUPRR, OF OHIO UNIVBRSITY, IN POPULAR SCIBNCB MONTHLY.]

{S2ontinued from pagt 236.)

Both medical science and philosophy, though not metaphysics, had
run their course by the time the Alexandrian era opened. A not incon-
siderable number of new facts were collected in Alexandria, but the
ability or the will to arrange them into an orderly system was lacking ;
at least we must adopt this view with the scant evidence to the contrary
before us. For more than a thousand years the one question asked

328 EBITORIAL COMMENT.

was not, What does nature say? What are the facts in the case? but,
What does the master say? Beginning with the first Christian cen-
turies, Europe and western Asia more and more became organized into
a society to suppress the increase of knowledge. It would not be easy
to say in which century this organization did the most eflFective work,
though there is no doubt that its most effective instrument was the
inquisition. As everybody knows, it was not theology alone that was
conservative; law and medicine were equally so. Goethe pays his
respects to this attitude of mind when he says in Faust:

Hear, therefore, one alone, for that is best, in sooth,
And simply take your master's words for truth.
On words let your attention center!
Then through the safest guide you'll enter
The temple-halls of certainty.

And again :

fcip Preoarc beforehand well your part

pflpiip.-r * With paragraphs all got by heart,
^i^***^ So you can better watch and look

That naught is said but what is in the book :

Yet in this writing as unwearied be l

As did the Holy Ghost dictate to thee.

This conservatism was a characteristic of the times ; the Protestant
revolution was hardly more than the beginning of a struggle for eman-
cipation in a single direction. It did not enlarge the intellectual horizon
of the lawyer or the physician. There is much evidence to show that
with the rise of the belief in witchcraft, medical science, using the term
in a very loose sense, received a distinct check. What was the advan-
tage of familiarizing one's self with the nature or usual progress of a
disease if its course was constantly liable to be interrupted by the will
of some malevolent being possessed of supernatural power? What was
to be gained by administering remedies that might at any time be ren-
dered nugatory by the same demoniacal interference? Those who
embraced the new faith promulgated by Luther were in some respects
worse off than those who clung to the old religion. While Catholics
and Protestants alike believed in witches and other agents of the devil,
the former had also their saints and the Virgin, to whom they could
appeal in time of temptation and distress and who were rarely appealed
to in vain. For the latter, Satan and his emissaries were no less real ;
but he had given up his faith in the efficacy of the intercession of the
saints and the Virgin. His only resource, therefore, was to protect
himself as best he might by dealing mercilessly with those who had
anything to do with the black art.

The late Herbert Spencer is said to have reached the conclusion
toward the close of his life that man is not a rational being. One can
hardly help subscribing to this creed when he learns the attitude of the
public toward medical practice. We can understand why there should
be a great deal of hazy thinking in matters of law and theology, since

PHYSICIANS AND PHILOSOPHERS. 329

they have to do with problems that are at best more or less abstract.
But why the public should willfully shut its eyes to practical benefits
in every-day matters, matters that so vitally concern its life and health,
is hard to understand. Yet it is no harder to understand than why a
stone will not of itself roll up hill. We can only realize this mental
asphyxiation in the face of overwhelming evidence. It is explicable
only from the standpoint of the universal belief in the utter powerless-
ness of man in the presence of the spirits that surround him and dwell
within him. Though the scriptures have much to say about casting
out devils, the belief in them is human rather than Christian, since it is
found among all the peoples of the globe, except among that small class
who may be called rationalists; or who, if not themselves entitled to
this designation, have inherited a rationalistic creed; for a rationalist
is simply one who refuses to believe anything except on such evidence
as his reason approves.

There are grounds for believing that Aristotle dissected human
bodies; at least on no other grounds can his correct information with
regard to certain points in anatomy be explained. But for prudential
reasons he did not deem it wise to make public how this knowledge was
obtained. Salerno seems to have been the first medical school in Italy
outside of Spain, that is, the earliest in charge of Christians, and the
probability is that its origin has some connection with the Arab dom-
ination. Bologna came into prominence in the thirteenth century and
retained its preeminence for a long time. Here we have some definite
statements by Mondino that he dissected several cadavers. But his
writings also furnish the proof that he was not able to emancipate him-
seif wholly from the authority of Galen and the Arabians. For some
reason there were fewer obstacles In the way of the anatomist in Italy
than in any other country in Europe ; Berenger of Carpi is said to have
performed more than a hundred dissections. In Italy, too, we meet
with a number of names that are immortalized by their discoveries in
the human body. The chief merit of Vesalius lies in the fact that he
clearly recognized for the first time many of the errors that had come
into current belief by the authority of Galen..

Hippocrates, Celsus, Galen, these three names sum up the science
of ancient medicine; but the greatest of these is Hippocrates. It is
perhaps not putting the case too strong if we say that they embrace
substantially the entire healing art until not much over a century ago.
The medical works of these three authors were printed in Italy before
the end of the fifteenth century in Latin translations from the Arabic.
This is striking testimony to the completeness of the rupture between
ancient Greece and dawning era of modern times. When these Latin
translations from the Arabic were made is not known ; but it is known
that they were very imperfect and that they were as blindly followed
as were the writings of Aristotle. Galen's prestige was more due to
his ambition and industry than to his individual merit. The great mass
of medical knowledge was still accessible in manuscripts. This he

330 EDITORIAL COMMENT.

carefully examined, and wrote comments upon much of it with remark-
able discrimination for his age. Like Aristotle he would have been the
first to repudiate the utterly senseless homage paid to his writings.
One cannot read the works of Hippocrates without being impressed
with the extraordinary acumen of the man. Much that now passes
current under his name is doubtless not genuine, in the strict sense
of the word; but is at least evidence to the prestige of the master's
name. The thinker constantly appears along with the practitioner.
And we must always keep in mind that chemistry was unknown and
the microscope nonexistant. He tells us, among other things, that
rain water is the purest, while ice and snow water are the worst for all
purposes. He had carefully noted the radical differences between the
people of Asia and of Europe, so far as he knew these parts of the
world. What he says concerns the physician but little, the philosopher
a great deal. He directly contravenes popular belief when he tells his
readers more than once that there is no such thing as a sacred disease ;
that no disorder is sent by a god, and that all ailments are due to
natural causes. How heterodox this was may be seen by any one who
reads the first book of the Iliad, where Apollo is represented as having
sent a pestilence upon the Greek host. In his discourse on ancient
medicine — a singular title for a book written more than four centuries
before the Christian era, whether by Hippocrates or some one else —
w^e find the idea of the survival of the fittest clearly indicated ; in fact,
many of the Greeks had more than an inkling of it. His apprehension
of gradual evolution is also shown by the assertion that the vegetables
used for food are the outcome of experiments with coarser kinds and
the deleterious effects upon the health of those that were rejected. He
takes the ground that a man cannot understand the medical art unless
he knows, as far as that is possible, what man is. He holds that the
physician should be skilled in nature ; but what he defines as "nature"
is not cosmological, it is rather the etiology of disease and the laws of
hygiene. He also speaks of the "common herd of physicians." Evi-
dently professional pride is, not the latest born of time's offspring.
Among the most interesting documents included among the writings
of Hippocrates is the physician's oath. While it may not have been
formulated by the master, it undoubtedly represents the principles of
his school. Thus early had Greek physicians formed themselves into a
guild and pledged themselves to certain rules of conduct. These guilds
were, however, not secret associations or fraternities and had no pro-
fessional arcana different from those of the present day. The novitiate
pledged himself to regard his teacher as equally dear with his own
parents; to hold his sons in equal esteem with his own brothers; to
teach them and his own sons the medical art without fee, if they
desired to learn it ; to keep aloof from whatever is detrimental to health ;
to give no deadly drug even when asked ; to pass his life in purity and
holiness ; to abstain from any harmful act in whatsoever house he might
enter for the benefit of the sick; to divulge no secrets connected with

PREPARED FOOD PRODUCTS. 331

his professional practice, and to refuse to administer to any woman a
drug that will produce abortion. It is evident from the oath here given
in substance that the morals of the medical fraternity were, at least
in theory, far in advance of those of the general public and of many
well-known philosophers by profession.

[thb bnd.]

MEDICAL NEWS.

THE SUDDEN DEMISE OF SCHAUDINN.

The profession will deplore the recent death of Doctor Fritz Schau-
dinn, the young German investigator, whose conjoint researches with
HoflFman on the spirochseta pallida have attracted world interest. Doc-
tor Schaudinn had recently been appointed to the directorship of the
department of parasitology of the Institute for Tropical Diseases at
Hamburg. His career, which was ruthlessly terminated at the age of
thirty-six, gave promise of being a brilliant one, and the medical pro-
fession as a whole will undoubtedly suflFer a distinct loss through his
premature demise.

PREPARED FOOD PRODUCTS.

The packing-house exposures have undoubtedly exerted a profound
influence upon the masses — ^not only in the United States, but in
Europe as well. As accurately as can be estimated the demand foi
prepared food stuffs has decreased to the extent of twenty million dol-
lars, and sixty per cent, of the packing-house workers are at present
unemployed. Many European markets have refused to handle certain
food products of American preparation, and the authorities in general
are exerting every influence to exclude supplies which manifest the
slightest trace of adulteration. That Upton Sinclaire's assertions with
regard to the frightfully unhygienic conditions of the Chicago stock
yards were, in almost every respect, founded on fact, is apparent from
the report of the government committee of two — Messrs. Neill and
Reynolds — which contains the following: "The neglect on the part of
their employers to recognize or provide for the requirements of cleanli-
ness and decency of the employees must have an influence that cannot
be exaggerated in lowering the morals and discouraging cleanliness
on the part of the workers employed in the packing-houses. The whole
situation as we saw it in these huge establishments tends necessarily
and inevitably to the moral degradation of thousands of workers, who
are forced to spend their working hours under conditions that are
entirely unnecessary and unpardonable, and which are a constant men-
ace not only to their own health, but to the health of those who use the
food products prepared by them."

332 MEDICAL NEWS.

ANNUAL MEETING OF THE ROENTGEN RAY SOCIETY.

The seventh annual meeting of the American Roentgen Ray Society
will be held at the Cataract and International Hotels, Niagara Falls,
New York, August 29-30-31, 1906, under the presidency of Doctor
Henry Hulst, of Grand Rapids, Michigan. A large and interesting
program, containing the names of the best jr-ray workers in this coun-
try, as well as a number from abroad, has been prepared. An interest-
ing feature of the meeting will be the exhibit of prints and negatives.
The railroads have granted a rate of one fare and a third on the certif-
icate plan. Full information regarding the meeting and application
blanks for membership may be obtained by addressing the secretary,
Doctor George C. Johnson, 611 Fulton Building, Pittsburg, Pennsyl-
vania.

MINOR INTELLIGENCE.

A SCIENTIFIC estimate places the loss of life from earthquake during
the past nineteen centuries at over two million.

The management of Oak Grove Hospital, Flint, Michigan, recently
issued a handsomely illustrated descriptive brocure of that institution.

Manila is suffering from an epidemic of cholera. Latest reports,
however, are to the effect that the authorities have the disease well
under control.

The International Congress for the Care of the Insane will be held
in Milan, Italy, during September. Preparations for the meeting ar(
already in progress.

Politicians in France accord more distinction to the medical guild
than they do in our own country. Forty-six physicians represent the
profession in the newly elected chamber of deputies.

Notwithstanding assertions to the contrary, the report of Doctor
J. H. White, of the Marine Hospital Service, informs the public that
there is not a single case of yellow fever in New Orleans.

Doctor Howard A. Kelly, of Baltimore, delivered the address at
the commencement exercises of the American Medical Missionary Col-
lege, in the Tabernacle, at Battle Creek, Michigan, June 18, 1906.

The medical profession has a slight claim upon the late Henrik
Isben, Norway's famous poet and dramatist. His business career was
inaugurated in an apothecary's shop, where he served an apprentice-
ship.

Honorary degrees were conferred on the following physicians at
the recent Commencement exercises of Yale College at New Haven:
Doctor William W. Keen, of Philadelphia (Doctor of Laws) ; Doctor
Francis Bacon, of New Haven (Doctor of Science) ; Doctor Henry H.
Donaldson, of Philadelphia (Doctor of Science).

MINOR INTELLIGENCE. 333

Fruit and candy on sale in the shops of Los Angeles, California,
have recently been investigated by the board of health of that city.
Discovery of the presence of many bacteria supposed to be conveyed
to these palatable articles by the wind has resulted in a request for
legislation demanding that they be exhibited in glass cases.

At a meeting held in Cooper Medical College, San Francisco, on
the 1 2th instant, the regents of the University of California voted to
transfer the work of the first two years of the department of Medicine
and Dentistry to the university buildings at Berkeley. The move is
made to afford more room in the college building for clinical work.

The failure of the German athletes to secure laurels at the Olym-
pian games, recently held at Athens, is attributed to their excessive use
of beer. Indulgence in the product has been the subject of specula-
tion among Teutonic investigators for some time, and journalists have
recently inaugurated discussion of the subject with marked enthusiasm.

At the Boston meeting of the American Gastroenterological Asso-
ciation the following officers were elected : President, Doctor Henry W.
Bettmann, of Cincinnati ; first vicepresident, Doctor Julius Friedenwald,
of Baltimore; second vicepresident. Doctor Frank H. Murdoch, of
Pittsburg; secretary-treasurer. Doctor Charles D. Aaron, of Detroit.

The Paris Medical Journal has recently been launched in the
French metropolis, under the editorship of Doctors Warden and Gras.
Its function will be to disseminate, in the English tongue, French
practices, researches, and discoveries. It should enjoy a large circula-
tion among English-speaking physicians who are interested in foreign
medicine.

The Jewish Maternity Hospital of New York City was recently
incorporated by the State Board of Charities. Plans for a new building
are already in the hands of the Board of Directors, and as soon as a
suitable site can be procured, the work of erection will be inaugurated.
The promoters desire to establish the institution on the lower East
Side of the city.

The Wayne County (Detroit) Medical Society elected the follow-
ing officers on May 21 : President, J. Henry Carstens ; vicepresident.
Doctor William F, Metcalf; secretary-treasurer. Doctor Walter D.
Ford; directors, Doctor George W. Wagner, Doctor H. Wellington
Yates, Doctor Louis J. Hirschman, Doctor Guy L. Kiefer, and Doctor
Frank B. Tibbals.

The organization of a guild to be known as the Southwestern
States Medical Association, and to which physicians from Arkansas,
Missouri, Texas, Kansas, and Oklahoma, will be eligible, is being
agitated. A committee has been appointed by the Arkansas State Med-
ical Society to formulate plans for its foundation. The idea is said to
contemplate secession from the American Medical Association of the
entire Southwest.

334 MEDICAL NEWS.

The medital building of Queen's University was destroyed by fire
on July 4. The conflagration is supposed to have had its origin in an
oil stove. The loss to the institution is estimated at one hundred thou-
sand dollars.

Doctor Austin Flint was presented with a silver loving cup by
the class of 1909 of Cornell University, on May 24, in commemoration
of his services as Professor of Physiology, which chair he recently
relinquished, after forty-five years' service. Doctor Flint's work will
be continued by his assistant, Doctor John A. Hartwell.

Doctor Henry P. Bowditch, who for the past thirty-five years
has occupied the chair of physiology at Harvard, recently severed his
connection with the institution. Doctor Bowditch was a well-known
teacher and his work has been recognized by many educational institu-
tions, he having received honorary degrees from Cambridge, Edinburgh,
Leipzig and Toronto.

The State College of Physicians and Surgeons of Indiana was
incorporated on May 23, 1906. The building formerly occupied by the
Central College of Physicians and Surgeons has been secured, and
operations will be formally inaugurated in September next. The insti-
tution will be a corporate part of the University of Indiana, and will
be under state supervision.

The female population of Nordhausen, Prussian Saxony, must
henceforth wear short skirts, or suffer the inconvenience of carrying
a long train high above the ground. The authorities have decreed that
the accumulation of dust upon the trains of fashionable skirts is detri-
mental to the public health, and a fine of seven and one-half dollars will
be imposed on breakers of the law.

The pure food agitation is affecting every section of the country.
The city physician of Little Rock, Arkansas, recently confiscated and
destroyed fifty gallons of milk which had been treated with formalde-
hyde as a means of preservation, and as a consequence an ordinance
has become vogue that henceforth venders of adulterated food, of
whatever nature, will be prosecuted.

While the list of dead and injured resulting from celebration of the
fourth of July stands as an argument against pyrotechnic display, the
number of fatalities for 1906 is a trifle smaller than for 1905. This
year fifty-three succumbed from wounds, as against fifty-nine for last
year. The number of wounded, however, was greater in 1906, three
thousand six hundred and fifty-five having received injuries.

At the recent meeting of the American Association of Pathologists
and Bacteriologists the following officers were elected for the ensuing
year : President, Doctor William H. Welch, of Johns Hopkins Univer-
sity; vicepresident, Doctor Aldred S. Warthin, of the University of
Michigan; secretary, Doctor Harold C. Ernst, of Harvard University;
treasurer. Doctor Herbert W. Williams, of the University of Buffalo.

PROGRESSIVE MEDICINE. 335

The sixtieth annual meeting of the Wisconsin State Medical Soci-
ety was held in Milwaukee on June 29. The following officers were
elected for the ensuing year: President, Doctor Levi H. Pelton, of
Waupaca ; first vicepresident, Doctor Arthur J. Burgess, of Milwaukee ;
second vicepresident. Doctor William E. Ground, of Superior; third
vicepresident, Doctor W. J. Pinkerton, of Prairie du Chien ; secretary,
Doctor Charles St Sheldon, of Madison; treasurer, Doctor Sidney S.
Hall, of Ripon. The next meeting will be held at Superior.

Doctor Charles Warren Allen, Professor of Dermatology in
the New York Postgraduate Medical School, died of typhoid fever at
Gibraltar, on May 31. Doctor Allen had been attending the Interna-
tional Medical Congress, having spoken at the Section on Radiology,
and was attacked with his fatal illness while en route home by way of
Naples. At Gibraltar his illness became so severe that he was per-
suaded to discontinue his journey. Doctor Allen was an authority on
radiotherapy, and contributed many valuable papers to radiologic
literature.

RECENT LITERATURE.

REVIEWS.

PROGRESSIVE MEDICINE— June, igo6.*

The second number of Volume VIII is devoted to the following
subjects : Hernia, Surgery of the Abdomen exclusive of Hernia, Gyne-
cology, Diseases of the Blood, Deathetic and Metabolic Diseases, Dis-
eases of the Spleen, Thyroid Gland, and Lymphatic System, and Oph-
thalmology. We have praised the merits of this quarterly visitor so
often that it seems unnecessary to say more. But for those who may
not be acquainted with the object of "Progressive Medicine" a few
words will not be out of place. "Progressive Medicine" is a yearly
summary of the world's best literature in all branches of medicine and
surgery. It gathers together an extensive bibliography of all the sub-
jects dealt with and presents its matter in such a way that one who
has endeavored to keep abreast of the times, feels that great justice has
been done the original articles by the reviewer. The knowledge
obtained from "Progressive Medicine" is very trustworthy.

In those parts devoted to surgery every new and important method
IS illustrated by copies of the original illustrations. The cuts are
clear in every detail. The book is executed in convenient form. As
yet we have no occasion to say aught against this valuable publication.

D. M. c.

*By Hobart Amory Hare, M. D. Lea Brothers & Company, pub-
lishers, Philadelphia and New York. Price, paper, $1.50.

336 RECENT LITERATURE.

A TREATISE ON DIAGNOSTIC METHODS OF EXAMINA-
TION.*

The fact that Sahli's work on diagnosis was not translated into
English long before this has been a matter of comment among all who
knew the value of the work. Even in the first edition, a very much
smaller volume than the latest, the book had a striking individuality.
It not only gave diagnostic methods with fulness and accuracy, but it
also gave explanations of the problems involved, physical, chemical,
physiological and pathological. From the fulness and soundness of its
discussions the work was indispensable to all who wished to go mosi
thoroughly into medical diagnosis.

The large body of medical students, postgraduate as well as under-
graduate, are to be congratulated upon the fact that the work is not
only available now in English but that it is put forward in the best
possible manner. The translation is good. The notes and additions
are accurate and discriminating and the mechanical execution of the
volume such as we have been made familiar with by the Saunders firm.
A successful career can be confidently predicted, and at the same time
we may expect that a great impetus will be given to the use of good
diagnostic methods by American physicians. a d.

*By Professor Doctor Hermann Sahli. Edited, with additions, by
Francis P. Kinnicutt, M. D., and Nathaniel Bowditch Potter, M. D.
Authorized Translation from the fourth revised and enlarged German
edition. Philadelphia and London: W. B. Saunders & Company,

A COMPEND OF OPERATIVE GYNECOLOGY.*

Bainbridge and Meeker have filled a long-felt want by producing
a little book of only sixty-six pages which considers all the important
gynecologic operations in a terse but comprehensive manner.

The book is intended primarily to serve as an aid to students taking
the course in operative gynecology in the New York Postgraduate
School. As an illustration of its scope we may cite the description of
the Alexander operation. The surgical anatomy receives attention
first: origin and course of the round ligament, its attachments, and
the position of the external ring. Next comes the technic of the oper-
ation : the incisions, and what they should accomplish ; the method of
uncovering and hooking the ligaments ; the method of producing proper
traction after freeing the ligaments; the cutting away of the slack
portion of the ligament and its subsequent anchorage. Materials used.
Aftertreatment. Various modifications. Objections to its use.

If, in the next edition, the authors would insert a good cut to illus-
trate each operation, the value of this book would be almost ines-
timable. It is a clear-cut rendering and has a field of usefulness because
of its comprehensive briefness and convenient size. d. m. c.

*The Grafton Press, Publishers, New York. Price, $1.00.

A PROFESSIONAL MEDICAL JOURNAL.

VOLUME XXVIII. AUGUST, 1906. NUMBER VIII.

ORIGINAL ARTICLES.

MEMOIRS.

THE VISUAL FIELDS AS AN AID TO DIAGNOSIS.

GEORGE SLOCUM, M. D.

DBMONSTRATOK OP OrHTHALMOIXXjY IN THB UNIVKSSITY OP MICHIGAN.

The term visual field is employed to designate the sensitiveness of
the whole retina to form. It is distinguished from central vision at the
macula by the expression, visual acuity, which is symbolized as V. or
V. A. Visual acuity is direct or axial perception, while the visual field
is the perception of form as characterized by the ability to see two
separate points at one and the same time over all sensitive portions of
the retina. It is the indirect vision.

The limits of the field of vision have two factors, the anatomical
configuration, namely, the eyebrows, lids, lashes, nose, lips, et cetera,
and, the limit of retinal sensitiveness at its peripheral portion. The
first factor is variable and must often be taken into consideration. The
second factor is also variable even in health. Fields are increased in
hyperopia and by the action of strychnia, and decreased in myopia.
Various ocular, cerebral, and general diseases, some of which may be
functional while others are organic, also decrease them.

It is to the diagnostic value of the visual fields, more particularly in
regard to extraocular and general disease, that I wish to direct your
attention, but before doing this a few remarks in regard to the methods
of taking visual fields may be of interest.

A simple expedient is that of seating the patient, with one eye cov-
ered, directly in front of the examiner, who also must close one eye,
his right for the patient's left and vice versa, and then, the patient's
other eye fixed on his, he carries an object from without his own field
directly in from above, below, without, or within, equally distant from
his and the patient's eye and compares the first perception of the
object by the patient with his own. This is only a rough approxima-

338 ORIGINAL ARTICLES.

tion but it will determine the presence of marked contractions or of
hemiopia. Large scotomata may also be found. The method of taking
' the fields with a blackboard is open to the objection that as an angle
of forty-five degrees is reached the distance of the test object rapidly
becomes so great that its mere remoteness serves to render it less dis-
tinct. The perimeter is practically much more valuable, and for
accuracy, indispensable. The instrument needs no description here.

The size of the test object is important. In general, for white, a
square of ten millimeters is satisfactory. Where the vision is low,
twenty millimeters is better, and in some cases a white card of ten to
fifteen centimeters with a black spot in the center five to ten millimeters
in diameter is exceedingly useful for accurate work. In locating scoto-
mata, the test object should not generally exceed one to five millimeters.
The examination should be made in good daylight and should be care-
fully conducted. The more painstaking the examination, the more
valuable does the chart become for diagnostic purposes.

The normal limits of the visual fields are approximately in degrees
as expressed by the chart: up, fifty; up and out, sixty-five; directly
out, ninety ; out and down, eighty-five to ninety ; down, seventy ; down
and in, fifty ; in, sixty, and up and in, fifty-five, with reference to axial
vision.

The color fields are as important for diagnostic purposes as the'
form, particularly, in their relation to that for white, and to each other.
They are arranged from without in, yellow, blue, red, and green in
order.

Of much importance also, for diagnosis, is the location, character,
and size of the various scotomata. A physiologic scotoma located about
fifteen degrees temporally from the axial center marks the jrfiysiolc^ic
blind spot or optic nerve entrance. It is a negative scotoma, a positive
scotoma being one of which the patient is conscious. Scotomata are
false when caused by opacities of, or foreign bodies in, the media, and
true when caused by defect of the receptive, conductive, or perceptive
apparatus. They may be in the central, itermediate, or peripheral zone,
and are irregular, concentric, central or paracentral. They are absolute
when all perception of light is lost and relative when acuity is dimin-
ished. The latter are color scotomata and are more generally for green
and red, blue being longest retained and therefore less often lost.

The relation of the color fields to that for white, as said before, is
very important. Where they diminish much more rapidly than that for
white and central vision is diminished, atrophy or pressure upon the
visual paths is usually present. Where the vision is rapidly lowered
by subdued light, as in twilight, the so-called hemeralopia, the color
fields are greatly restricted and disappear if the fields are taken in such
light, while at the same time the form fields are undiminished. Purely
functional conditions as in the neuroses, often present contracted fields
for white with characteristic change of those for colors. Peripheral
defects are divided into concentric contraction, contraction with sector-

VISUAL FIELDS AS AN AID TO DIAGNOSIS. 339

like defects, and sector defects with the remaining portion of the field
normal, or nearly so, the latter often extending nearly to the point of
central fixation.

Brief mention only will be made of most of the intraocular condi-
tions causing visual defects. The diagnostic value of these fields is
greatly enhanced by associated ophthalmoscopic examination.

The fields are restricted in retinitis pigmentosa, circular detachment
of the retina, glaucoma, atrophy, and hysteria, in all of which there is
concentric contraction.

Hemiopia or half sight, whether temporal, nasal or transient shows
a marked limitation or suppression of one-half of the field.

Central scotomata are found in tobacco or other toxic amblyopias,
in retrobulbar neuritis, in embolism of the retinal artery, and in central
choroiditis. Scotomata and contractions occur also in papillitis, retinitis
and choroiditis. Irregular scotomata are seen in atrophy, choroiditis,
coloboma, detached retina, irregular hemorrhages, nephritis, foreign
bodies and opacities of the media.

An enlarged blind spot is seen in opaque nerve fibers and in retinal
and choroidal coloboma, while retinal hemorrhages may cause irregular
scotomata with or without concentric contraction.

In embolism of the retinal artery blindness usually results, but in
those cases where the macular branches are given off in the nerve
below the embolism, central vision may be retained. Here the field will
correspond only to the then unaffected portion of the macula. When
the embolism is limited to a retinal branch, a sector defect will appear.
Occasionally there is a cilioretinal artery present. When this is the
case vision may be preserved only in that portion of the retina supplied
by it or it may itself be the seat of the embolism, in which case there
would be a large central scotoma corresponding to the area supplied by
the cilioretinal artery.

In retinal detachment, the fields will show a marked contraction or
sector defect corresponding to the detachment, which, unless recovery
takes place, usually increases in size.

The change in retinitis pigmentosa is typical, there being concentric
contraction, with marked decrease of the color fields and their complete
loss in poor light. Other forms of retinitis, neuroretinitis and choroid-
itis present marked changes not typical.

When the underlying cause is syphilis the normal field is often
restored by appropriate treatment.

Perhaps the most important diagnostic significance of the visual
fields in intraocular affection is in glaucoma. In this disease the fields
are usually contracted most nasally, for the nasal field is that which
falls on that portion of the retina without the macula and this being
farthest from its blood supply, it is therefore most easily affected by
the cupping and pressure at the papilla. Associated with this contrac-
tion more or less reduction of the visual acuity is seen, which gradually
increases as the disease progresses, and at the same time that the con-

340 ORIGINAL ARTICLES.

traction increases. In simple glaucoma, however, central acuity may
not diminish in proportion to the progress of the disease as the nerve
fibers partially accommodate themselves to the slowly increased pres-
sure.

Occasionally, a central scotoma develops, which spreads to meet the
advancing contraction, or, central vision may remain normal, or nearly
so, until a large part of the field is lost.

Following iridectomy, visual acuity may greatly increase and the
fields become largely restored, the restoration being more marked in
the inflammatory type. The ophthalmoscope in the early stage of
glaucoma shows hyperemia with perhaps pulsating arteries. Later,
marked cupping and atrophy appear.

In choked disc, the fields are not proportionately affected, although
a considerable increase of the blind spot is generally seen. If the disease
progresses and atrophy follows, the fields are similar to those of simple
atrophy and they gradually decrease to blindness. Early treatment, sur-
gical in tumor, or medical in syphillis, et cetera, may bring about partial
restoration of the fields.

In tabes dorsalis and dementia there is in fifteen to eighteen per
cent of cases, a progressive optic atrophy, in which the fields are con-
tracted irregularly, and central acuity is diminished. This is associated
with disturbed pupillary reflexes, in which the pupil looses its light
reaction through retaining that for accommodation. When atrophy is
present the pupils are dilated, often irregularly. The ophthalmoscope
shows atrophy of the nerve head, with vessels reduced in size, and
slight cupping, as in simple atrophy.

In central and spinal syphilis, the fields may show partial or con-
centric reduction with areas of retention in the periphery. There may
be unilateral blindness with temporal hemiopia in the other eye. The
central vision is variable and there may, in localized gumma of the
tract, be a complete central scotoma. The ophthalmoscope may show
neuroretinitis, papillitis, choked disc, simple atrophy, or there may be
very little change. The pupils are affected proportionately as vision is
lost, being dilated and inactive in the advanced atrophic stage.

In multiple sclerosis there are central scotomat^, usually relative
with very little, if any, contraction of the periphery. The scotomata
may disappear, reappear, or there may be complete recovery of central
vision ; on the other hand, the field may diminish as in tabes, or atrophy
may follow\ The results of ophthalmoscopic examination are character-
istic only of the secondary condition. The visual acuity is lowered
in proportion to the gravity of the lesion. The pupillary reaction may
or may not be disturbed.

Retrobulbar neuritis often gives a large central scotoma which may
increase or become stationary. There may be a concentric scotoma or a
central color scotoma. Visual acuity is variable. The pupil is sluggish
with the reflexes present. The ophthalmoscopic examination is not
characteristic, unless the atrophic stage is reached, when there will be
paling of the temporal portion of the disc.

VISUAL FIELDS AS AN AID TO DIAGNOSIS, 341

In hereditary neuritis, the conditions are similar to those in retro-
bulbar neuritis.

In tobacco and alcohol and other toxic amblyopias, there is an oval
scotoma for red and green located between the point of central fixation
and the blind spot. Absolute scotomata are rare. There is little or no
contraction. There may be complete loss of perception of red or green
while white is normal in extent. Where caused by alcohol, the per-
iphery may be contracted. In poisoning by methyl alcohol there is
a more marked descending neuritis with quite often complete blindness
accompanied by atrophic changes, the fields varying proportionately
and the prognosis being relatively bad. In other forms of toxic ambly-
opias the prognosis is generally good with proper treatment. In toxic
amblyopias the ophthalmoscope gives paling of the temporal half of
the discs, with some retinal congestion, particularly to the nasal side.
The visual acuity is lowered in proportion to the severity of the neuritis
but it is much better in poor light, owing to the dilated pupil and the
greater number of cones stimulated.

In disease of the chiasm there may be one of the hemiopias present,
which, because of the arrangement and crossing of the nerve fibers
varies according to the location of the lesion. If the lesion is at the
anterior portion, at the location of the crossed fibers, the nasal halves
of the retinae will be aflFected and there will be bilateral temporal hemi-
opia. If the outer portion or uncrossed fibers are diseased there will be
Unilateral nasal hemiopia. A few cases of bilateral nasal hemiopia have
been reported. In these cases, there are symmetrical lesions.

In hemiopia, the macula may not be at all involved, which is
explained by supposing a double inervation from each cortex, that is,
both sides of the macula may have crossed and uncrossed fibers. There
may be temporal blindness of one eye, and only partial temporal blindness
of the other, or, it may be partial in both eyes, or one eye may be blind
with temporal hemiopia of the other. The ophthalmoscope may show a
choked disc, neuroretinitis, or intraocular disease not dependent upon
the lesion of the chiasm. Visual acuity may be lost, diminished or
retained, in one or both eyes according to the extent of the process, and
whether the macular bundle is destroyed, merely compressed, or is
unaffected.

In syphilitic cases, the fluctuation of the visual defects should lead
to suspicion of a specific cause, when appropriate treatment may restore
the field.

Homonomous hemiopia is produced by lesions of the optic tracts,
primary ganglia, optic radiations, or cortical center in the cuneus. It
is never seen in hysteria, unless as a complication. Homonomous
hemiopia may result from disease, pressure, irritation or extension of
a disease process, the prognosis depending upon the character and dura-
tion of the cause. If the lesion is in the right visual apparatus, the left
fields are hemiopic and vice versa. The line of separation may bisect
the visual axis or the axis may in those cases of double innervation be

342 ORIGINAL ARTICLES.

unaffected. A double innervation is the only plausible explanation for
the overshot field. If only a partial homonomous hemi(4>ia exists, the
lesion but partially destroys the affected portion. There may be sym-
metrical scotomata from the same cause. The defects are absolute if
typical but relative changes for red and green, and sometimes for blue
are seen. Visual hallucinations may occur in the blind fields. The
color fields, in the unaffected portion may be, and usually are, normal.
Homonomous hemiopia from involvement of the primary centers is
usually associated with hemiplegia and hemianesthesia of the same
side as the hemiopia, and is further characterized by absence of the
hemiopic pupillary reaction sign ; this is also absent when the tract is
affected, but if the lesion is back of the primary ganglia the pupillary
reaction sign is present. In these cases, the color fields may be hemiopic
while that for white is altered but little, or not at all. In destruction
of both cortical centers, pupillary reaction is retained if the primary
ganglia and tracts are unaffected.

The prognosis in field disturbance is unfavorable when the con-
traction of the field is increasing or the scotoma spreads ; when the color
fields are constantly diminishing, and when red or green are not per-
ceived. The disease process has a tendency to improve when the limits
of the fields for white and colors increase ; when white improves and the
colors remain stationary; when red and green sight is regained after
having been lost ; when the field remains of the same size when using
a smaller-sized object in testing. The effect of strychnine must be con-
sidered if the patient is taking it. When the retrogression ceases the
condition may remain permanent at this point.

In functional disturbances of the fields of vision, concentric con-
traction with reduction of the color fields is characteristic. In these
conditions there is a nervous asthenopia, in which letters run together
or disappear, or there is photopsia, visual hallucinations, sudden diplo-
pia, megalopsia, micropsia, epiphora and blindness in bright light, while
pupillary reactions and ophthalmoscopic pictures are normal. There
is, in these cases, concentric contraction of all the fields, but the contrac-
tion is regular instead of markedly irregular or tooth-shaped, as is
general in organic affections. The limits for blue, red, or gjeen, may
approach or cross, or replace each other in some portion of the field.
The power to distinguish color is diminished. There is rapid retinal
tiring with production of fog-like fading of the fields. The size of the
fields is changeable from day to day. One field may be large and the
other small.

In hysteria, considerable stress is placed upon the replacement of
red by gjeen. Though this may be regarded as pathognomonic, it is
generally present only in limited portions, and the red almost as fre-
quently overlaps or approximates the blue field. All grades of ambly-
opia to total amaurosis may be associated with hysteria though the
pupillary reactions are unaffected. Spasm of the accommodation may
stimulate amblyopia in an hysterical subject as well as in the non-

ANEURYSM OF THE ABDOMINAL AORTA. 343

hysterical. It must be eliminated. Hysterical fields are rarely if ever
hemiopic, nor are there scotomata. They differ from those of neuras-
thenia only in that the colors replace each other more ownpletely in
hysteria, although some fields of people suffering from neurasthenia are
remarkably similar to those of hysteria.

REPORT OF CASE OF ANEURYSM OF THE ABDOMINAL

AORTA.

PAUL S. MILLER, A. B., M. D.

[from THB CLIMIC of INTBRNAL MBDICINB, UKIVBBSITY op MICHIGAN.]

It is entirely probable that abdominal aneurysm was recognized by
Vesalius himself, while in 17 19 Valisneri made a diagnosis of aneurysm
most important will be mentioned.

It is entirely probable that abdominal aneurysm was recognized by
Vesalius himself, while in 1719 Valisneri made a diagnosis of aneurysm
of the abdominal aorta, and verified this subsequently by section (Mor-
gagni). Despite this earlier recognition, our first accurate knowledge
of this condition dates from the publication of Beatty's case in 1830
('^Dublin Hospital Reports," Volume V. A synopsis of the case may
be found in Stokes' work, "Diseases of the Heart and Aorta," 1838.)
The value of Beatty's work is due to the accuracy and realism with
which the symptoms are described, and the careful observation of the
order of their appearance. The case was under observation continu-
ously during the years 1827, 1828, and 1829, during that time being
seen and examined by many noted physicians. In 1836 we have the
report of an interesting case by Sir David J. H. Dickson, physician to
the Royal Naval Hospital at Plymouth ("Medico-Chirurgical Transac-
tions of the Royal Medical and Chirurgical Society of London," Vol-
ume XXI.) This case was one of enormous -ventral aneurysm of the
abdominal aorta, with findings at necropsy. A great number of cases
have been reported in the literature since, but Beatty's case still remains
as a classic in the symptomatology of aneurysm of the abdominal aorta.
Stokes has collected a number of cases in his work on the "Heart and
Aorta," and his consideration of the entire subject is one of the most
complete and accurate to be found in the literature today.

Aneurysm of the abdominal aorta itself is not of frequent occur-
rence. It is hardly possible to give a definite ratio between this con-
dition and the concurrence of aneurysm elsewhere in the body, because
the comparative figures differ so in various localities. In Vienna,
according to Schrotter, in two hundred twenty-two cases of aneurysm,
only three were of the abdominal aorta. At Saint Bartholomew's Hos-
pital the figures are placed by Oswald Browne at one to twenty. About
sixteen per cent of cases of aneurysm occurring at Guy's Hospital
between the years 1854 and 1900 were of the abdominal aorta (J. H.
Bryant in Clinical Journal, 1903). Osier, in his article in the Lanoet
of October 14, 1905, places the comparative occurrence at about one

344 ORIGINAL ARTICLES

in ten. These figures would seem to indicate that the condition, while
comparatively rare, is not so infrequent in its occurrence as is com-
monly supposed. The disease, however, is not often recc^^ized, and
in a large number of cases the diagnoses is only made at autopsy.

The symptoms of aneurysm of this portion of the aorta are often
very obscure, and the physical signs misleading. In the case reported
by Beatty the patient was repeatedly seen and examined by Graves,
Cheyne, B'rodie, CoUes, Townsend, Wilson Phillip, and Andral, during
the years 1827, 1828, and 1829. Andral made a diagnosis of a "rare
form of intestinal neurosis." The real condition was only discovered
at autopsy. Bryant, in his article (Clinical Journal, 1903), says that in
only eighteen out of the fifty-four cases, on which his lecture was
based, was a correct conclusion arrived at during life. Analysis
showed that an abdominal tumor was detected in thirty-one, pulsation '
in thirty-five, expansile pulsation in eight only, and a systolic murmur
in twenty-six. Incorrect diagnoses of a variety of conditions were
made. R. Travers Smith (Dublin Journal of Medical Sciences, 1905,
Volume CXX) reports a case of proving at autopsy to be aneurysm of
the abdominal aorta, in which diagnosis had been made of "renal cal-
culus with hydronephrosis." Often in cases such as this operative pro-
cedures are undertaken, and the results, while unavoidable, are regret-
table in the extreme.

The great majority of cases occur in the male. Aneurysm of the
abdominal aorta in the female is rare. This is of importance because
of the frequent occurrence of pulsating aorta in nervous or hysterical
women, which has often led to a diagnosis of aneurysm.

Etiologically, Osier considers syphilis as the all important factor
in cases occurring before the age of forty ^earsi A general atheroma-
tous condition is usually present in the arteries, while the heart is sel-
dom affected. Alcoholism is the rule. Nephritis, gout, and rheuma-
tism are factors to be considered, while manual labor has apparently
but little relation with the condition. A great majority of cases occur
before the fiftieth year.

The following case is of interest, because of the misleading symp-
toms which characterized the beginning of the trouble.

The patient was admitted to Doctor Dock's clinic in the University
Hospital, at Ann Arbor, late in the afternoon of October 14, 1905. The
following notes were made by myself a short time after his admission.
Patient, male, age forty-five years, occupation, that of laborer. His
chief complaint at the time of admission is of a feeling of pressure in
the epigastrium, and about the heart, stomach trouble, and inability to
sleep because of constant pain of a dull, boring character, also parox-
ysmal pains of a sharp, cutting nature in the left lumbar and iliac
regions. Concerning the patient's family history nothing worthy of note
can be obtained. During the past ten years the patient has had trouble
wth stomach and bowels. The stomach trouble is described as a feel-
ing of fulness and distress after eating. This has gradually become

ANEURYSM OF THE ABDOMINAL AORTA. 345

worse during the last few years, until at present, after the ordinary
meal a feeling of weight and discomfort is noticed, or, in the words of
the patient, he "feels as though there was a stone in his stomach."
Constipation has always been the rule. Patient uses tobacco and alcohol
immoderately. Specific infection was denied, but he admits having had
gonorrhea. Some time previous to the commencement of the present
trouble he says that he was kicked by a horse, the hoof striking his
abdomen. About six weeks previous to the date of his admission here,
there had been a marked increase in the severity of his gastric symp-
toms; loss of appetite, marked distress after eating, and a feeling of
nausea, but no vomiting. At this same time he noticed the presence of
a dull, intense pain in the epigastrium and left hypochondrium.

The patient first saw a physician on the 20th of August, and from
the doctor's case history the following extract was taken: "When
first seen the man presented all the symptoms of an acute gastritis, and
was treated accordingly. For some days improvement followed. On
the 25th I was called hurriedly to see the patient and found him suflFer-
ing great pain and highly excited. On examination I found the tem-
perature to be 102°, pulse 138; friction sounds were believed to be
heard over the heart ; stomach distended ; nothing found on abdominal
palpation. Suspicion of pericarditis was entertained. On the follow-
ing morning the temperature^ was normal, pulse 99, friction sounds
absent. Patient was last seen on the 12th of September, and at that
time he was apparently much better."

After this, according to the patient's story, he became worse; the
dull pain became more intense, until now it is of a constant, boring
character. Also daily paroxysms of sharp, cutting pains, of agonizing
character, come on during the evening, or at night. During these
attacks he is unable to He down, blit is compelled to walk about. Pres-
sure over epigastrium at times gives some apparent relief. About three
weeks ago the location of the pain changed, and now it is more appar-
ent in the left iliac and lumbar regions. Nausea is present, but at no
time has vomiting occurred. The patient complains of a continuous
feeling of pressure about the heart, also a sensation of impending death.

Since the beginning of the trouble the patient has consulted several
doctors, and diagnoses of "tobacco heart," "neuralgia of the heart,"
"pressure upon the nerves of the heart," et cetera, have been made.
The patient has lost some weight.

Status Prasens. — Patient presents rather an emaciated appearance,
and has an anxious, worried expression of countenance. Lungs : Neg-
ative. Heart: Apex in the fifth intercostal space, just inside the nipple
line. Heart dulness not enlarged to the right of the sternum. Soft,
blowing, systolic murmur heard over the apex, and along the left
border of the sternum. A soft, blowing, systolic murmur is heard at
the base. Radial pulse, is full and bounding. Abdomen : Abdomen is
on a level with the ribs. In the epigastrium, just to the left of the
median line, is a tense tumor mass, about the size of a small orange.

346 ORIGINAL ARTICLES.

The mass is expansile, and the impulse is synchronous with the apex
beat. It does not descend on inspiration. Over the mass is felt a faint,
fine thrill, and on auscultation a harsh, prolonged, systolic murmur is
heard. The femoral pulse is of slow rise and fall, and of lower tension
than the radial.

Diagnosis. — From the long continued presence of pain in the epigas-
trium, and in the iliac and lumbar regions, from the character of this
pain, dull and boring, with paroxysms of a sharp, agonizing nature,
and its association with the presence of an expansile tumor in the
epigastrium, the impulse of which was synchronous with the diastole,
diagnosis of aneurysm of the abdominal aorta was made.

The patient being considerably exhausted as a result of his long
journey to the hospital, and subsequent examination, was sent to his
bed in the ward with instructions to keep as quiet as possible.

I again saw the patient about 7 o'clock that evening, and at that
time he was feeling very comfortable. It was noted by others in tfce
ward that about 2 o'clock the following morning the patient became
restless, walking up and down the ward with hands clasped over the
abdomen, occasionally groaning. He finally returned to his bed where
he remained for a time. After this he walked from the ward into the
adjoining sun parlor, where he remained for a few moments with hands
pressed against abdomen, and in a crouching position. Patient then
started for his bed in the ward, stumbled and fell against the door, but
managed to reach his bed, upon which he fell, uttering several loud
cries, and struggling for breath. I had been called in the meantime,
but when I reached the patient, which was at 2 145 a. m., he was dead,
lying on his right side with hands firmly pressed against the epigas-
trium and left side.

Postmortem, — This occurred at 3 o'clock the following afternoon,
and was performed by Doctor Butterfield. The following is an extract
of the findings :

Body, one hundred fifty-seven cubic centimeters in length ; 'frame,
large; muscular development, good; visible mucous membranes, pale.

Abdomen: Slightly below the level of the ribs. Large, irregular
abrasions on left lateral thoracic region. No scars on skin or penis.
Rigor mortis marked throughout. Body heat absent. Slight greenish
discoloration in the lumbar region. Abdominal muscles dark ; pannicu-
lus bright yellow. About one hundred cubic centimeters of blood-
stained fluid in the abdominal cavity. Parietal peritoneum smooth and
glistening. Colon prolapsed in a V-shaped manner, reaching the umbil-
icus; intestines moderately distended. Diaphragm on the left at the
lower border of the sixth rib; fluctuation obtained through it. On
the right the diaphragm is at the lower border of the fourth rib.
Pleural cavities : A large quantity of thin blood-stained fluid is found
in the left cavity, with a huge clot weighing one thousand nine hundred
sixty-five grammes, which completely surrounds the upper lobe and

ANEURYSM OF THE ABDOMINAL AORTA. 347

part of the lower lobe of the left lung. The right pleural cavity is
almost obliterated by old adhesions.

Left lung : This is pushed forward into anterior mediastinum, over-
lapping the median line. Lung is small, crepitant throughout, and-
emphysematous at the apex. On section the cut surface is moist, grey-
ish-white ; clotted blood in interlobar pleural space. Weight, two hun-
dred fifty-five grammes.

Right lung : Firm, crepitant in the upper lobes ; in the base there is
marked hypostatic congestion and diminished crepitation. Weight,
three hundred twenty grammes.

Heart : Musculature is pale and firm. Heart is not enlarged. The
mitral valve presents nodular masses on the free margin of the leaflets.
The tips of the papillary muscles are fibrous. The tricuspid leaflets
are slightly thick. The pulmonary valves are normal. The aortic
cusps are large and slightly nodular along the free border.

Pericardium : This contains a few cubic centimeters of straw-colored
fluid. Both layers of the membrane are smooth and glistening.

Aorta: In the abdominal aorta, ten cubic centimeters above the
bifurcation, there is a large sac, about ten by seven centimeters in
diameter. The superior pole of this sac has burrowed through the left
leaf of the diaphragm close to the vertebral column, the opening into
the diaphragm being about one and one-half centimeters in diam-
eter, ragged, thick and infiltrated with clotted blood. The sac is
directed towards the left, posteriorly and externally, overlying the left
adrenal. It lies behind the fundus of the stomach extending as high as
the lesser curvature, but it does not reach the median line of the body.
The celiac axis, the renal, and the superior mesenteric arteries spring
from the sac. The sac contains a mixed clot and a small amount of
fluid blood. The aneurysm springs from the lateral wall of the aorta,
its orifice being two centimeters to the left of the mouths of the
lumbar arteries, roughly oval in outline, and measuring four by two
and one-half centimeters. The margins are extremely thickened and
contain an abundant deposit of lime salts. The wall of the aorta at
the mouth of the aneurysm shows advanced sclerosis and atheromatous
nodules, and is twice as wide as the portion immediately above the
origin of the sac. Below the orifice of the aneurysm the aorta shows
slight pouch-like bulging, four centimeters long, and directed exter-
nally towards the left. From this bulging portion springs the inferior
mesenteric artery. The retroperitoneal tissues in the left lumbar fossa
are edematous and infiltrated with blood. The arch of the aorta is
extremely capacious and shows advanced sclerosis; the ascending
portion of the arch measuring eleven centimeters in circumference.

Spleen: This organ is bound down by old adhesions; capsule lax.
On section the pulp is a dark purplish-red, moderately soft and clings to
the knife. The trabeculae are obscure, and but few Malpighian bodies
are seen. Size, 12.5 x 7.5 x 3.5. Weight, one hundred fifty grammes.

348 ORIGINAL ARTICLES.

Adrenals : These show slight postmortem change.

Left kidney: The perirenal fat is abundant. Numerous cysts are
found beneath the capsule, the largest being about the size of a marble.
On section the cortex is pale, labyrinth indistinct and cloudy, pyramids
pale, glomeruli invisible. Cortex measures four centimeters. The
capsule strips easily, leaving a slightly granular surface. The cysts
contain a clear, light-yellow fluid. Size, 9.5x5x3 centimeters.
Weight, eighty-five grammes.

Right kidney : This is much smaller than the left. In the upper and
anterior quadrant there is an enormous cyst. Cortex, six to nine centi-
meters. Otherwise the organ is similar to the left kidney. Size, 12 x
6.5 X 4 centimeters. Weight, two hundred fifty grammes.

Liver: Surface smooth; consistence medium; borders sharp. On
section the parenchyma bulges above the surface, and the markedly
accentuated central veins stand out sharply against the yellowish-
opaque parenchyma. Size, 25 x 20 x 6.5 centimeters. Weight, one
thousand three hundred thirty grammes.

Gall-bladder: Moderately distended with yellowish, tenacious bile.

Stomach : Very slight atrophy is shown. Intestines negative. The
mesenteric and retroperitoneal lymph glands are moderately enlarged,
hemolymph glands enlarged and pale pink on section.

Bladder: This contains a small quantity of turbid, yellow urine.
The walls are thin and the mucosa pale. The prostate is enlarged and
moderately firm. Testes apparently normal.

All the superficial lymph glands, inguinal, femoral, axillary and
supraclavicular, are moderately enlarged; the inguinal glands being
about the size of a hazelnut, greyish-white, homogenous, glistening and
rather firm on section.

Microscopical findings : In the nodular thickenings in the aorta, the
intima is from four to five times its usual thickness. The increase is
due to numerous elastic fibers, and a collagenous substance. Nuclei
are very scarce. Beneath the intima there is a structureless material
containing numerous cholesterin clefts. The aneurysmal sac shows
on the inner surface a layer of fibrin, then a layer of necrotic and
infiltrated tissue, external to which the tissues show marked inflamma-
tory reaction, fibroblastic proliferation, and hemorrhagic areas. In the
neighboring muscle there are atrophy, inflammation and areas of regen-
eration. The arteries and arterioles around the sac show marked
sclerosis, many being calcified.

In reviewing this case it is interesting to consider the way in which,
during the early stages, the symptoms of the aneurysm were obscured
by those arising from the stomach itself. From the long continued
anorexia and distress following eating, one would suppose some func-
tional disturbance of the stomach, but the microscopical findings in that
organ following autopsy were negative. In fact the association of these
symptoms with pain of a dull, persistent nature led to a diagnosis of
gastritis, and treatment of a dietetic nature afforded relief for a time.

ANEURYSM OF THE ABDOMINAL AORTA. 349

As to the cause of these symptoms and relief afforded by such treat-
ment, one cannot definitely say. It is possible that the causative factor
may have been the location of the tumor itself, its proximity to the
fundus and lesser curvature of the stomach ; in such a case it is entirely
probable that the ingestion of solid food, or food digested with diffi-
culty, by distending the organ and producing active peristalsis would
increase the pressure symptoms and produce distress and increase of
pain. In this case some relief would be obtained by the use of liquid
and easily digested food.

In reviewing the literature a number of cases are found presenting
gastric disturbances during the earlier stages, and in a few the entire
course of the disease is marked by such symptoms.

In Osier's series of sixteen cases of aneurysm of the abdominal aorta
occurring at the Johns Hopkins Hospital during the last sixteen years
(Lancet, October 14, 1905, page 1089), nausea and vomiting were
associated with the pain in two of the cases recorded. Cordier reports
a case (Lancet, 1905, Number I, page 1718) in which the symptoms
throughout the course of the disease, simulated those of dyspepsia.
The patient, a male, thirty-five years of age, complained of indigestion
ifor a period of two years. He suffered from pain coming on five or
ten minutes after eating, lasting for an hour or more. Discomfort was
lessened by dieting, but never left altogether. Before admission he
used liquid diet almost exclusively.

Status Prasens. — Patient thin, moist, face drawn and anxious. Skin
inelastic, bowels constipated, heart and lungs sound, no history of
syphilis. Some pulsation in the epigastric notch extending to the left
of the median line. On deep pressure there was a feeling of resistance,
but no definite tumor. On auscultation, a faint, blowing murmur was
heard, localized in a space about the size of a five-shilling piece. No
diminution of pulse wave. The pain increased in the epigastrium and
back, and was more marked at night; used iporphine continuously.
Sudden death.

Autopsy. — An aneurysm about the size of a small pear, involving
the whole of the celiac axis, and the anterior wall of the aorta was
found. The wall of sac was ruptured, and peritoneal cavity filled with
blood.

In this case Cordier explains the pain after eating by the relation
of the aneur>'smal sac to the stomach, and also thus explains the conse-
quent benefit on dieting.

In Beatty's noted case, published in 1830 ("Dublin Hospital
Reports," Volume V. A brief synopsis of the case may be found in
Stokes' work), pain followed the ingestion of food afld eructation of
gas was common, often affording relief from the distress. In this case
also there were marked spasmodic attacks of pain in the intestinal tract,
resembling painter's colic, leading Andral to make a diagnosis of rare
form of intestinal neurosis.

350 ORIGINAL ARTICLES.

A case of Doctor Lee's is recorded by Stokes ("Diseases of the
Heart and Aorta," Case LXXV). The patient, a male, age forty-
eight, had bad health for two years, the illness commencing with acute
pain in loins, and distressing sensations attributed to flatulent disten-
tion and debility. Anorexia, frequent vomiting, difficulty in swallow-
ing, the effort causing pain. Emaciated and cachectic in appearance,
lately suffering from cough and palpitation.

Status Prasens. — Pulse 120, small and feeble. Heart action strong
and excited. Abdomen retracted, lower portion of chest dull from the
sixth rib down posteriorly. Feeble respiratory murmur. In the left
hypochondrium a round, hard, incompressible, and apparently immov-
able tumor was felt, presenting diastolic pulsation, most distinct at
inner and outer portions. Sharp bellows-murmur heard when patient
was in recumbent position, not propagated along the course of the aorta
nor discernible over inner part of tumor. The pulsation of the tumor
would almost disappear with patient in the erect position. Patient died
suddenly after muscular exertion. An aneurysm of the abdominal
aorta found under the left lobe of the liver, depressing the pancreas,
burst into the peritoneal cavity. The eleventh and twelfth dorsal ver-
tebrae were eroded.

The preceding cases all have some similarity as to form of gastric
disturbance, if not in the degree to which they were affected. In the
latter period of the case here reported pain was the prominent subjec-
tive symptom. It was present in both the dull, boring character, and
in the sharp, neuralgic form. The remarkable severity of the pain is
to be explained by the situation of the aneurysm itself. The higher the
location of the sac in regard to the vessel the greater the pain. In this
case located just below the diaphragm and adherent to the left leaflet,
the pain was extreme. The view is taken by some that the dull, boring
pain is due to erosion of the vertebra, but in this case there was not the
slightest evidence of erosion, and in the Hterature there are numbers
of cases in which the characteristic pain is present but no erosion has^
taken place. It would seem that the more probable view is that which
has been advanced considering the pain due to the stretching of nerves
and tearing of tissues by the sac itself.

Rupture into the pleural cavity is a frequent termination in such
cases. In Beatty's case death occurred in this manner. In one case
observed by Doctor Lyons, in Meath Hospital (Stokes' "Diseases of
the Heart and Aorta"), the patient fainted under examination. On
recovery it was noticed that the left side was dull as high up as the
lower edge of the scapula. Diagnosis was made of rupture of aneurysm
into left pleural cavity. The patient lived twenty-four hours, and the
diagnosis was verified by necropsy.

In my case the points of chief interest are :

The presence of symptoms referable to the stomach, which obscured
to such an extent the real condition as to lead to the diagnosis of gas-
f tritis.

LESSONS IN LONGEVITY. 361

The occurrence of exacerbations in the course of the disease, while
in the interim the patient was comparatively easy.

The disproportion between the violence of the symptoms observed,
and the apparent constitutional disturbance.

In the later stages the presence of a feeling of pressure about the
heart, and presentment of impending death.

From the review of this case and the features in its course which
are worthy of note, the conclusion now is the same as that drawn by
Stokes sixty-eight years ago, namely, that "in all cases of violent neu-
ralgic affections engaging the region of the diaphragm, the dorsal or
lumbar spinal region, or the abdominal viscera, the patient should be
examined for aneurysm ; more especially if the disease be remittent, and
the general health in earlier period unaffected."

The importance of thorough and systematic abdominal examination
in all such cases cannot be overestimated, for oftentimes much light is
thrown upon otherwise obscure conditions.

LESSONS IN LONGEVITY.

JOHN S. CAULKINS, M. D.
THIRD PAPER.

For every human infant bom the Parcae cut off with their shears
from the web they spin a portion of stamen zntce as a heritage to the
child. This modicum of vitality is its full apportionment, and must
last it through infancy, childhood, youth, manhood, and the decay of
old age to the end of the mortal journey. The piece snipped off for
each child is not always of the same size, but varies widely from gener-
ous to scant, being allotted by the operation of laws of which we are
most profoundly ignorant, the laws of heredity and atavism, but be it
more or less, this inheritance of vitality, carefully used, measures out
the length of life possible to its owner. It is not known or probable
that any increment can be made to this vital stock to help carry its
owner past his proportional time, but it is very certain that it can be
wasted, and its owner live but a fraction of the days to which a thrifty
use of it would entitle him.

There are two conditions, then, requisite for the new comer on this
mundane sphere to insure him a long and useful career: first, to be
well bom, that is, to have behind him a line of hardy, healthy, long-
lived ancestors; and secondly, to make the best possible use of his
inheritance of vital force. During his earlier years the child has as
little to say about this second requisite as he has about the first, but
he has rights if he can get them, birthrights, and the greatest of these
is the right to instruction and guardianship against hurtful things.
To impart this instruction and guardianship to its rising generation is

352 ORIGINAL ARTICLES.

a public duty, and any nation neglecting it does so at its peril. Agisa-
laus, the wise king of the I^cedonians, being asked twenty-three
hundred years ago what it was best to teach children, replied, "those
things that will be of most use to them when they have grown up."
No wiser answer can be given today than this, and we can learn from
it the necessity of teaching the child, as fast as his intellect expands
sufficiently, to avoid everything that will tend to rob him of his right-
ful share of vital force, and hinder him from growing up to be a hale,
sound old man capable of doing in his turn for those who come after
him, enough to repay the debt with accumulated interest owed by him
to his own predecessors. This is the way to progress.

The instruction must be founded on a strictly scientific basis, letting
whatever lacks that wear its own distinctive label of probable, pos-
sible, conjectural, or whatever its true value may be, thus avoiding the
danger of warping the developing mind out of its true shape and
making the reception of a new truth difficult. The instruction ought
to touch on every phase and relation of human life, physical, mental,
or moral that can influence the development of a ''mens sanis in corpore
sane,'' but we must here give our attention to the physical mainly.

Diet, ventilation, sleep, exercise, study, habits, work, and play must
receive consideration, and anything and everything else pertaining to
the simple life, but above all is the primal need of teaching children the
knowledge and avoidance of whatever tends to waste their share of
inherited vital force. This is the substratum of the whole training. First
impressions are lasting. However erroneous they may be it is hard
work to scrape them out of the mind. It is important to write cor-
rectly on the sheet of white paper and avoid the drudgery of erasing
errors. A palimpsest is not so satisfactory as the original manuscript.
It is of comparatively little use to preach to adults. The growth is out
of them ; their minds are warped in some direction ; their preferences
are made and they are impatient of contradiction. . It is difficult to get
them to look at things dispassionately, and if any new impressions are
made they are apt to be very transient. It is the plastic mind of the
young that should be molded into the normal and correct form that
vvill need to undergo no change while life lasts. "Train up a child in
the way he should go, and when he is old he will not depart from it."

" 'Tis education forms the commoii mind.
Just as the twig is bent the tree's inclined."

These are sound maxims and will seldom disappoint the educator,
but there is a practical difficulty in the way, and that is the want of
teachers who teach by example as w^ell as by precept. Children are
imitative and learn best by example. They may be familiar with the
best text-books, but seeing the sanitary rules taught in them generally
disregarded, they naturally fall into the same ways and do themselves

LESSONS IN LONGEVITY. 363

irreparable injury. I say "irreparable" advisedly, for every injury is
that. Every fit of sickness, every overexertion, exposure or extreme
of any kind diminishes the reserve of vital force and there is no way
to get it back. Every expenditure of vital force beyond the daily need
IS at the expense of some future day. Life is an equation, one side of
it must equal the other. The store of vital force equals the number of
days you can live. If you live fast, two days in one, you must live one
day less; or1t is like your fortune, the faster you spend it the sooner
you will come to want. You cannot get something for nothing ; as the
proverb goes, you cannot have your cake and eat it too. The law is as
inflexible as those of the Medes and Persians. Few will dissent from
these premises as a general rule, but many will continue to act as if
they themselves were exceptions to it and make no effort to reform
their unsatisfactory habits. Young says, in his "Night Thoughts,"
"All men think all men mortal but themselves." Beyond assenting to
the right education of the children perhaps little can be expected of the
adults of the present age by way of inaugurating effort for the scientific
improvement of the human race through prolonging the average
duration of life.

With regard to the first requisite mentioned above as needful for
long life, that of being well born, we will dismiss it with the remark
that improvement in that direction must at present only keep pace with
that of the general conditions, the world not being ready yet' for radical
reforms bearing on progeny, but the time is coming when the public
will have something to say about the matter of who shall beget the
children and who shall mother them. Just another remark: The
chance to be well born will be far better when wars are abolished, as
they must be soon. War is a fatal drain on a nation. It removes the
best and leaves the propagation of the species to the poorest, reversing
the law of the survival of the fitteist. The wars of Bonaparte, for
instance, drained France of her most vigorous young men and she has
not yet recovered from the syncope caused by the drainage. We have
seen how easily Germany alone overran a country that seventy-five
years before, successfully resisted the efforts of all Europe, when the
tyrants, alarmed at the birth of human freedom, united to trample it out
and put the worthless Bourbons back on the throne of France. When
disarmament comes and the world agrees to settle its differences by
arbitration instead of fighting over them, the immense sums of money
now spent for the armies, fleets, fortifications and whatnot, can be
applied to useful purposes. The scientific development of the human
species will then proceed rapidly; the cause of all diseases, including
old age, and the means of their cure, will be ascertained; the "how
to be well born" will be studied; the laws of heredity and atavism
discovered and applied to the prolongation of human life so that the
two-hundred-year limit spoken of by Hufeland and .referred to in a
former paper (see his "Macrobiotik," page 109, Erasmus Wilson's
edition) may be attained.

354 ORIGINAL ARTICLES.

Seeing that we must leave this subject to the future and admitting
that there is no great probability that adults will listen to reason and
break away from injurious habits, our field of labor is necessarily lim-
ited to the education and development of the young in the direction
alluded to above, and we will discuss the items in the schedule seriatim,
first of all —

Diet. — Here Nature tells us plainly that the infant needs no nutri-
ment but milk. After the lactation period cow's milk supplants
mother's, to which is added, as needed, solid food, farinaceous and
saccharine at first, and then fruits, nuts, and vegetables; no animal
food, except eggs and dairy products, being served until the deciduous
teeth are shed. So far the teachings of Nature seem clear enough, but
what does she say about the use of flesh and fish after the second den-
tition? Opinions differ here, but in practice flesh and fish constitute a
large part of the diet of all children who live in cold and temperate
regions ; less so in the torrid. There is much to be said on both sides of
the question. Some believe the reason primeval man evoluted from his
congeners, the anthropoid apes, was because he learned to be a killer
and to eat meat. Others laugh at this and hold that man would be a
much more lovable and gentle animal now, if his progenitors had never
learned to kill for their living, and consider meat eating as only one
degree above cannibalism. The question is too large to be settled in
this short paper, but it is suggestive to remember that the dentition of
man is not the dentition of a carnivorous animal, and the same can be
said of his intestinal canal. Another suggestive fact is that the greatest
age among the land mammals is attained by the elephant, camel, mule,
and horse, which are strict vegetarians. Whichever side is taken this
cautionary remark can be made that during the period of growth, feed-
ing too much meat would tend to develop a small stomach, a relatively
large one being desirable as a safeguard against indigestion and
dyspepsia, and especially valuable when only coarse foods are obtain-
able.

Dietary studies are of supreme importance to the welfare and
improvement of the human race and great developments in them are
soon to be looked for.

Ventilation, — The study of this is of no less importance than that of
food, oxygen being a vital necessity. To breathe impure air is equiva-
lent to eating poisoned food. No child can grow with the capacity of
living a long life unless he has been raised in a well-ventilated house,
and every adult can shorten his natural span of life by neglecting a
good supply of oxygen for his bedroom. This essential in summer is
not difficult to obtain, but a problem arises in winter, especially with the
very poor, when coal is costly. A cubic foot of air passes through a
good pair of lungs in about five minutes and renders approximately
ten times its volume of atmosphere unfit to breathe because of a diffu-
sion of expelled carbon dioxid and animal poisons. Sinking to the
floor, if no exit is found, its level would constantly rise until in two

LESSONS IN LONGEVITY. 355

hours or so the occupant of a bed two and one-half feet from the floor
would be immersed in the poisoned air. This poisoned air must have
an exit. It is a good precaution to keep the foot of the bedstead a little
lower than the head to allow the expired air to drain away from the
nose. An angle of eight or ten degrees is enough to allow for that.
This has been the habit of the writer all his life and hence this advice'
to others.

The proper ventilation of bedrooms by night is a problem that
requires careful study. Testing the air for oxygen will show that no
bedroom has it, even the best cared for, in a state of purity quite fit for
the complete purification of the btood, without which perfect health
cannot be had. The practical difficulty lies between getting enough
pure outdoor air to breathe and conserving heat enough to be comfort-
able. We can dodge this in the summer by sleeping in the open,
a plan hardly practicable in winter. The only way, then, is to let in as
much warm air as will replace the outgoing respired air, but this is at
best only a partial remedy ; complete purity cannot be obtained. The
standard would be more or less lowered unless a brisk breeze blew
through the bedroom all night. The carbon dioxid can be easily
eradicated, the chief trouble being with the deadly animal poisons
eliminated by the lungs and skin which impart a vile smell to close
bedrooms. The problem of the future contemplates finding some gas
that will act as a scavenger to rid the room of these impurities. It will
be a distinct step in the evolution of the improved and long-lived man
when a human being, from his first inspiration to his last, can breathe
as good air by night as by day, but even then there will be roc»n for
improvement, for day air in the house is only relatively good, never
showing any reaction in testing for ozone, the scavenger of the air.

With regard to ventilation there is one simple rule which, though
it does not discover the whole ground, is useful as far as applicable. It is
simply this : beware of all odors, they are signs of danger. Under the
head of ventilation, clothing is included, just as diet includes drinks
as well as eatables. It is as necessary to ventilate the man himself as
it is the house he lives in. There ought to be a certain hardening pro-
cess in the raising of children. We must get nearer to nature and
study how the lower animals can endure changes of temperature which
would be intolerable to man without apparent disc(Mnfort. It is plainly
to be seen that we are too much mollycoddled. We wear too many
clothes and shut ourselves and children in hot, tight rooms until we lose
our resisting and accommodating power and become easy prey to a low
temperature. The writer can quote himself as an object lesson in this
regard. In his long experience as a frontier physician, and one who
never refused to go in the greatest inclemency of weather, he never
froze ear, finger, or toe, and never wore anything to protect the ears —
muffler, tippet, or fur cap; just a common soft hat. The use of the
expression, "hardening process," is just a way of speaking, there being
really no such thing. What is meant by it is the avoidance of every-

366 ORIGINAL ARTICLES.

thing, acts, habits and influences that tend to enervate and weaken our
power of resistance. In other words, it means the conservation of the
vital force we receive from our parentage. To carry out this so-v^alled
hardening process there are things to do as well as things to avoid, and
preeminent among these is the judicious indulgence, especially by the
young, in swimming in summer and cold bathing in winter. For the
latter there are various ways that will do, but there are none so useful
and pleasant as this : being warmly clothed, break through the ice into
water to the neck, scramble out and hustle to the house to put on dry
clothing before the reaction is over. A run of twenty-five or ihirty
rods home is about right in zero weather. The delightful glow that
begins as soon as the water in the saturated clothing turns to ice, is
incredible to one who has never been encased in such a rattling panoply !
The mischief done by the overcoddling of children is immense. Its
immediate result is shown in their higher death-rate, and later on in
the enfeebled and enervated constitutions of those who do not succumb
in infancy. Some remarks that Hufeland makes under this head are very
pointed and well worth quoting. He says ("Macrobiotik," Chapter I,
Part 2) :

"There is no surer method of rendering the vital thread of a
being from its origin, short and perishable, than by giving it, during
the first years of life, which may be considered as a continued gen-
eration and expansion, a very warm, tender and delicate education;
that is, by guarding it from every breath of cool air ; burying it for at
least a year among pillows and blankets and keeping it like a chicken
in a real state of hatching ; not omitting to stuff it immoderately with
food ; and, by chocolate, coflFee, wine, spice, and such-like things (which
for children are nothing else than poison) to irritate it beyond measure
and to render its whole vital activity too strong and violent. By these
means its internal consumption is from its birth so accelerated, its
intensive life so early exalted, and its organs rendered so weak, tender
and sensitive, that one may expect that by two years* treatment of this
kind an innate vital capacity of sixty years may be reduced one half;
nay, as experience unfortunately shows, to much less, without reckon-
ing those evil accidents and diseases which may besides be the conse-
quence. The premature expansion of our organs and powefs is by
nothing so much hastened as by such a forced education, and we have
before proved w^hat an intimate connection there is between rapid or
slow expansion and a longer and shorter duration of life in general.
Speedy ripening always carries along with it speedy destruction. This
certainly is one great cause of the dreadful mortality among children.
But men overlook those causes that lie nearest to them and assume
rather the most absurd, in order that their minds may be at rest, and
that they may have as little to do as possible."

Hufeland then gives us, in a footnote, the following instance of
early maturity and early death :

"One of the most remarkable instances of prematurity of nature?

LESSONS IN LONGEVITY. 357

was Louis II, King of Hungary. He was born so long before the time
ftat he had no skin. In his second year he was crowned ; in his tenth
he succeeded to the throne ; in his fourteenth he had a complete beard ;
in his fifteenth he married ; in his eighteenth he had gray hair ; and in his
twentieth he died."

Sleep, — Of equal or greater importance to the development of the
individual man and the race, is the right regulation of sleep. Sleep
is much more than Young describes in his much-quoted and famous
line in the "Night Thoughts."

"Tired Nature's sweet restorer, balmy sleep."

Besides being this, it is the molder and artificer of physical beauty and
perfection, and it regulates itself. It is automatic if the two forces —
diet and ventilation, work correctly. No child, nor adult in that case
can sleep too much. Hufeland (generally so correct) disagrees with
this view and speaks of sleep as something to be regulated. His exact
words are: "No one should sleep less than six or more than eight
hours. This can be established as a general rule." Looking at this
dictum as merely a careless way of stating what the normal duration of
sleep for the human family should be, the time is not so much out of
the way, though somewhat too small ; but taking it to mean an alarm
clock to awaken us from sound sleep, or some kind of mechanical device
to tip the bed up and spill us onto the floor at a given hour, it is all
wrong. Sleep is as automatic as secretion, respiration, or heart-beat,
and must not be rudely disturbed. It is not extravagant to say that
whoever can sleep nine hours during the winter every night, adds that
one hour above the maximum of eight to the evening of his life.
Sound, natural, wholesome sleep is one of the main factors in con-
serving the inherited vital force and in building up a cellular stability
that will prolong life and make old age vigorous. The time will come
when the physical strength and beauty of the human race will be
increased through the agency of sleep to a point of which we cannot
now conceive, while it will be at the same time a prime factor in tho
prolongation of the span of human life.

The remaining topics can be conveniently treated of under one
head. They are habits, exercise, study, work, and play. Exercise
comes partly from play and partly from study, as we shall see; habits
are a part of study, and work is no part of a child's business untU the
period of growth is over. The business of a child is play at first and
later study. Any idea of commercialism ought to be rigidly excluded.
There will be time enough for that when the period of youth is over,
commercialism in a child being an unlovely trait and not to be developed
too early.

Habits, — In the list of things that the child has an inherent right to
be taught there is none of more paramount importance and urgent
necessity than teaching him to avoid contracting the habit of using any

368 ORIGINAL ARTICLES.

kind of a stimulant, basing the instruction on the solid, impregnable,
uncompromising position that the temporary good effect derived from
the habitual use of any such stimulant is at the expense of the stock of
vital force. It is like living on borrowed money : the more you borrow
and squander, the sooner you will be bankrupted.

In saying that work was no part of the business of a child, work as
a task was meant. Practically a large amount of instruction that later
will be useful can be imparted disguised as play, and as children always
like to learn to use tools valuable hints as to the future of the individual
can be obtained.

To play and be instructed is all that should be exacted of a child
until the growing time is over, and the two should go on tc^ether.
Since the knowledge of Nature and her laws is the source of all other
knowledge it follows that as soon as the three R's are mastered, the
study of the natural sciences should begin, but not in the way they are
now taught, from books merely. Botany and geology are the nearest
to Nature's heart and acquaintance should be made with them, with
competent instruction in the field, using books for reference only;
chemistry and other natural sciences later, leaving the higher mathe-
matics, languages, and literature to the last.

Now that we come to speak of the study of Nature we have, in the
opinion of the writer, reached the point which is the key to the desid-
eratum : the key to that longer life of which we are talking. It is
found in the search for and the study of the varied forms of Nature.
The law briefly stated as applied to brain or muscle seems to be like
this : exercise of either, if pleasant, strengthens and develops, if unpleas-
ant, tires out and weakens. It is this that gives the student of Nature
his claim on a long life. The cell formation in muscle and brain going
on while pleasantly engaged is stable, the muscle hard and strong, and
the brain cells, having furnished pleasant innervation, are equally
strengthened. No weariness having been felt, no drain has been made
on the stock of vital force. It is conserved for future use. An
enthusiastic botanist tramping the fields, woods and swamps, digging
roots, climbing trees and wading brooks in search of specimens, will
undergo five times the exertion without any sense of discomfort or
weariness that would completely exhaust him in some distasteful
pursuit.

Figure to yourself the immense saving the naturalist makes. One
of his assets is the forgetfulness of all worriments, and that is a great
thing. Worry is a negative quantity in the equation of life. Shake it
off whenever you can and by so doing raise the value of the equation.
No one is so free from worry as the naturalist. His studies lead him
into a region so free from storms and tempests that they are eminently
conducive to the prolongation of life. It cannot be too strongly insisted
on that everyone who wishes to reach an enjoyable old age should have
a hobby of some kind. The plan may look a little silly to you at first

LESSONS IN LONGEVITY. 859

sight but perseverance in it will bring its reward, and convince you of
its wisdom.

There has been in all ages of the world as now, an eager search
after the means of prolonging life, and in some cases with better
success than attends our present efforts. This was notably so with the
ancient Greeks. Their philosophers were men of great serenity of
mind, free from boisterous passions or any tinge of luxurious habits
and lived to a great age. Hippocrates, the father of medicine, and
Democritus, the laughing philosopher, lived to one hundred nine ; Xen-
ophilus, the Pythagorian, to one hundred six, and others still longer.
The Greeks made a great use of olive oil externally and internally. It
was believed that this offset the drying up that old age brihgs with it
and added to their longevity. For all we know to the contrary the
belief may have been well founded.

During the dark ages, belief in the elixir of life was universal and
every alchemist made it the constant object of search, and some,
Paracelsus and Saint Germain among them, claimed to have found
it, but in spite of their great discoveries, Paracelsus only lived to forty-
eight years, and the other to no great age. About three hundred years
ago Francis Bacon, the celebrated author of the "Novum Organum,"
the book that laid the corner stone of modern science, thought he had
discovered a way to prolong life by the use of opium and a depleting
regimen of low diet and cathartics every three years till the blood was
well reduced in quantity, to be then followed by a change to the most
nutritious diet possible until the vascular system was well filled again.
He followed his system until he was sixty-five, but at last had to give
up and go the way of all the earth. So far no such short cut to the
prolongation of life has been found, but there is good reason to hope
for some positive results from the work and studies of Metschnikoff at
the Pasteur Institute, Paris. He has already shown that the shrinkage
of tissues and hardening of the coats of the arteries in the old is the
work of microbes, and the next step is to find a way to stop their
ravages. He is reported to have said that he sees no insuperable obstacle
to hinder the solution of the problem.

One of the Hebrew prophets predicts the time when the days of a
man shall be like the days of a tree, and adds that the sinner, being
accursed, should die a hundred years old. The sinner dying accursed
would mean the man who obstinately refused to obey the wholesome
laws of sanitation and died from his excesses prematurely, in youth,
a hundred years old, instead of living until his days were like those of
a tree, the days of a tree being counted by the hundreds of years.
When science has made its boldest flights and given us a more adequate
idea of the laws and limitations of what Victor Hugo calls that
"unknown thing," meaning the lamp of life, and the human race
decides to live and govern itself by its light, the predicted time will
arrive and the days of a man will be like the days of a tree.

The next paper will discuss the moral and mental aspects of longevity.

300 ORIGINAL ABSTRACTS.

ORIGINAL ABSTRACTS.

GYNECOLOGY.

REUBEN PETERSON. A. B.. M. D.
rmowwmom or gtiibcologt and OBsrvnucs m rum UNivsssmr or Michigan.

AND
CHRISTOPHER GREGG PARNALL. A. B^ M. D.

VOBMBBLT WIMST AlSISTAIfT IW GYMSCOLOOT AMD OMTSTmiCS IN TNS UMIVBKSmr OP MICHIGAN.

THE CAUSES OF STERILITY.

Ward {American Journal of Obstetrics, Volume LIV, Number
II) comments on the low birth rate of the American bom population,
and in explanation of the apparently increasing sterility of American
women considers a number of factors.

First of all the husband may be impotent, and in a large percentage
of cases he is the cause of the condition. This percentage has been
estimated at from sixteen to seventy.

Sterility due to functional or organic defects in the woman may
be absolute or. relative according as to whether conception is impos-
sible or not. Sterility is more common as the social requirements of
women are increased. Women are much more apt to become pregnant
during the middle period of sexual activity, that is from twenty-five
to thirty-seven years of age. Sexual incompatibility is shown to be an
occasional course of sterility, as after a sterile marriage divorced
couples may reproduce with new partners.

In a study of sterility the essential factors necessary to a conception
must be considered ; They are : ( i ) the production of healthy sperma-
tozoa; (2) the production of a healthy ovum; (3) union of the
spermatozoon with the ovum; (4) implantation of the fertilized ovum
in the uterine mucosa.

With regard to the first factor, except under rare conditions,
gonorrhea is the cause of unhealthy spermatozoa in almost every case
where the male is at fault.

Sterility, resulting from absence of healthy ova, is met with in cases
of nondevelojMnent of the ovaries, acute and chronic inflammation, long
continued congestion, fibrosis, neoplastic formations, constitutional dis-
orders, and other diseases affecting remote organs.

The union of the male and female elements may be prevented
through various causes. Malformations, obstructions resulting from
stricture, and new growths, displacements, leucorrhea, operative fail-
ures, et cetera, would all tend to make it difficult for the spermatozoon
to meet and unite with the ovum.

Concerning the fourth factor, the implantation of the ovum, a
large number of cases of sterility are probably due to a failure of this
process. Endometritis whether due to infection or passive congestion

INFANTILE PARALYSIS. 361

prevents the proper lodgement and nutrition of the fertilized ovum.
Sterility accompanying fibroid tumors is probably due to the associated
change in the endometritun.

The writer believes that the majority of cases of sterility are due
to mechanical obstruction resulting from adnexal inflammaticHi, and
a large proportion of the remaining cases he attributes to disease of
the endometrium. Gonorrhea, being the most common cause of tubal,
ovarian, and endometrial inflammation, is consequently the most
important factor in the causation of sterility. cap.

Jackson, Michigan.

PEDIATRICS.

ARTHUR DAVID HOLMES, C. M., M. D.

ACUTE ENCEPHALITIS AND POLIOMYELITIS IN CHIL-
DREN AND CEREBRAL AND SPINAL INFANTILE
PARALYSIS.

Leonard Guthrie says {Clinical Journal, July 5, 1905) it is now
recognized that acute encephalitis and anterior poliomyelitis are one
and the same disease. In the former the affection is of the brain ; in
the latter it is of the spinal cord. So we may speak of cerebral and
spinal infantile paralyses. Sufficient postmortem evidence has been
obtained to establish the pathologic identity of the two affections.

In infantile spinal paralysis the morbid anatomy shows acute con-
gestion, thrombosis of the small vessels, cell exudation, and small hem-
orrhages into the gray matter of the anterior horns supplied by the
anterior spinal arteries. This leads to softening and necrosis of the
areas involved, owing to the cutting off of the blood supply. In time
the necrotic products become absorbed, contraction and cicatrization
occur, with atrophy or destruction of the ganglionic cells. Doctor F.
E. Batten has discovered precisely similar initial changes in the sub-
cortical area of the brain in one case of fatal and acute hemiplegia in a
child ; and in another, in which paralysis of the seventh nerve with death
from respiratory failure occurred, he found in the medulla congestion,
and perivascular exudation, with destruction of the facial nucleus.

Thus we may consider that cerebral and spinal infantile paralysis
are pathologically identical. There seems little doubt that, as Doctor
Batten contends, the primary condition is one of thrombosis of small
blood-vessels, but as yet it is undecided whether such changes are due
to specific infection producing acute inflammation, or whether the
thrombosis is dependent upon altered blood conditions arising from
different causes. In favor of an acute specific infection may be urged
the existence in epidemics of both iorms and their prevalence in cer-
tain months, notably in late summer and in early autumn.

This suggests bacterial invasion, but at present no specific bacteria

362 ORIGINAL ABSTRACTS.

have been identified. On the other hand, the cerebral form, at all
events, of infantile paralysis has so frequently occurred in the course
of, or in the wake of, acute specific diseases, such as morbilli, pertussis,
diphtheria, scarlatina, and influenza, that it is difficult to regard the fact
as a mere coincidence. And yet it is certain that both forms may occur
independently of any coincident or preceding illness. On the whole, it
seems most probable that some specific organism is present, and that
its action is favored by the existence or by the lowering effects of one
or other of the specific fevers.

The onset of both forms is usually marked by grave constitutional
disturbance. In poliomyelitis, except in very mild cases, there is,
usually, a sudden invasion, with headache, pains in the back or limbs,
vomiting, pyrexia, and sometimes convulsions. In a few hours or days
one or more limbs are found flaccid and motionless. The limbs are
often exquisitely tender on handling. In time pain, tenderness, and
fever subside, and entire limbs or certain groups of muscles in them
are found to be paralyzed and flaccid. The muscles waste, the tendon
reflexes disappear, and the electrical responses show the reactions of
degeneration, whilst the temperature and circulation of the affected
limbs are lowered. The paralysis is always at first more extensive than
can be accounted for by the actual extent of the destructive lesion, and
it is only after the lapse of time that the amount of damage caused
can be ascertained. In acute encephalitis the initial symptoms are
more severe and lasting than in the spinal form. The onset is usually
sudden; pyrexia, headache, vomiting, delirium, unconsciousness, and
convulsions are common. A condition of stupor or semiconsciousness
may last for days or weeks, with affections of special senses, such as
sight, hearing, speech, loss of sphincter control, and more or less wide-
spread paralysis or paresis and sensory disturbance. As in the spinal
form, the initial symptoms are usually more widespread than the lesion
would appear capable of producing, so the prognosis must always be
guarded. Sooner or later there are local signs which indicate the true
or chief extent of the mischief, and these will vary according to its
situation. In many cases the condition would seem not to advance
beyond the stage of congestion and perhaps temporary thrombosis of
small vessels, for otherwise recovery could not be so complete as in
many cases it is.

Two forms of acute encephalitis are described: polioencephalitis
superior, which may affect (i) the prefrontal convolution of the brain,
in which case profound and lasting mental changes may result; (2)
the motor areas, either of the cortex or descending motor tract, giving
rise to hemiplegia or diplegia; (3) the cerebellum or its peduncles, in
which case disturbance of equilibrium and ataxy are the consequences ;
(4) the occipital lobes, producing (probably) blindness due to the
involvement of the double half-vision centers. Polioencephalitis infe-
rior is so called when the nuclei beneath the corpora quadrigemina are
attacked, and the result is strabismus or various kinds of ophthalmo-

SINUS AND JUGULAR THROMBOSIS. 363

plegia, or when the bulbar nuclei are involved (acute bulbar palsy), in
which case any or all of the bulbar nerves may be paralyzed. Some-
times the cranial nerves rather than their nuclei seem to suffer, just
as in the spinal form a condition of polyneuritis is sometimes more
apparent than poliomyelitis. In some cases encephalitis seems to be
subacute and gradual in effect rather than acute and rapidly productive
of paralytic symptoms. Recognition of acute encephalitis as a by no
means common disease may prevent the error of mistaking it for tuber-
culous meningitis. This is a point of practical importance considering
the great difference in the mortality which attends the two diseases.
The conception of a primary thrombosis of smaller blood-vessels as
the starting point in both forms is also of importance. It affords a
simple explanation of recovery from symptoms which seem to indicate
the most extensive lesion. A mild and temporary condition of throm-
bosis is not incompatible with complete restoration of function. The
degree of recovery attained will depend entirely on the amount of struc-
tural damage which the thrombosis occasions.

Detroit t Michigan. ^^^^^^^^^^^^^^^^^^^

OTOLOGY.

R. BISHOP CANFIELD, A. B., M D.

PROPBSSOR OF OTOLARYNGOLOGY IN THE UNIVBRSITY OP MICHIGAN.
AND

MARSHALL LAWRENCE CUSHMAN, M. D.

DBMONSTRATOR OP OTOLARYNGOLOGY IN THB UNIVBRSITY OP MICHIGAN.

SYMPTOMS AND TREATMENT OF SINUS AND JUGULAR

THROMBOSES.

Kennon, of Norfolk, Virginia, in the June number of the Archives
of Otology, discusses this subject and prefaces his remarks with a
question as to the frequency of occurrence of the so-called characteristic
signs of this condition, namely, chills and rapid temperature fluctu-
ations. His observations, based on a series of fifteen cases, bring out
the following signs and symptoms :

(i) Temperature, which may or may not show a sudden fluctu-
ation in height, and which, if attaining to a height of but ioi° to 103°,
in an opened mastoid, may indicate operative measures.

(2) Chills, which, though frequently absent, are significant if
present.

(3) Respiration, varying with the temperature.

(4) A rapid pulse, rising simultaneously with the temperature, to
140 or 150 and seldom falling to normal even though the temperature
does so fall.

(5) Cutaneous signs, as sweating after a chill, or a dry, parched
skin when the chills are absent. Late in the disease the skin assumes a
yellowish hue.

364 ORIGINAL ABSTRACTS.

(6) Fetid breath, cracked lips, and sordes, often leading to a diag-
nosis of typhoid fever.

(7) Absence of mental symptoms except as induced by extreme
temperatures.

(8) Early in the disease the strength of the patient, and later a
condition of marked emaciation and asthenia.

(9) Optic neuritis is rarely present.

(10) Local signs are unreliable, the presence of granulations on
the sinus wall arguing against its involvement, as they act as a protect-
ive barrier to infection. Palpation is misleading and the experiment
of Whiting is dangerous.

Under treatment, the author advocates early operation and free
opening of the sinus, from the knee to the bulb if necessary, great care
being taken to avoid setting loose, in the general circulation, pieces of
the infected thrombus. When the bulb or jugular vein is involved a
rapid resection of the latter should be done.

In his last cases, instead of resecting the vein from the clavicle to
the bulb, Doctor Kennon has removed that portion below the facial
and has brought the upper end out into the skin wound, thereby avoid-
ing any infection of the neck.

Five cases are reported. m. l. c.

LARYNGOLOGY.

WILLIS SIDNEY ANDERSON, M. D.

ASSISTANT TO THB CHAIR OP LARYNGOLOGY IN THB DRTROIT COLLBGB OP MBDICINB.

NOTES ON THE PATHOLOGY OF FIFTY CASES OF
INNOCENT LARYNGEAL GROWTHS.

Doctor Wyatt Wingraves ( The Journal of Laryngology, Rhinol-
ogy and Otology, May, 1906) gives very briefly the abstract of the fifty
cases, and a concise summary of his conclusions. He classifies them
morphologically under two types: (i) Epithelial (papillomata) ; (2)
Mesoblastic or connective tissue growth. The first is essentially
epithelial in structure and origin, while the second consists of growths
composed of elements varying only in degree from the original vascu-
larized areolar tissue from which they grow, covered with the normal
or modified epithelium of the region, and ought to be described as
papillomata. He gives the microscopic structure of these growths and
discusses their etiology as follows :

"With regard to the probable origin of these papillated and pen-
dulous innocent growths, it is only reasonable to infer that many of
them are associated with primary inflammatory conditions. A consid-
eration of their pathogeny would, however, be incomplete without refer-
ence to local developmental processes. This has a special significance
in connection with those growths found in the region of the anterior

TREATMENT OF PRURITIUS ANI. 365

commissure. At an early stage of the development of the glottis the
vocal cords are continuous anteriorly in the form of a web or a sickle-
shaped band, which normally undergoes suppression, but, in some
instances, persists even to adult life. Should the modelling of this
commissural web be imperfect, tags of tissue may be left, which might
eventually constitute pendulous growths, especially should the subjects
become mouth-breathers.

"In the case of pure papillomata, or warts, irritation is an accepted
factor in their pathogeny, and no situation is more favorable to that
influence than the larynx, especially in habitual mouth-breathers, for
lar3mgeal papillomata have been reported not only as coexisting with
adenoids, but also as having spontaneously disappeared after the
removal of the postnasal obstruction.'*

PRIMARY ACTINOMYCOSIS OF THE NECK, WITH RAPID

EXTENSION INTO THE TRACHEA AND BRONCHI.

Casteneda (Revue Hebdomadaire de Laryngologie, d'Otologie et
de Rhinologie, May 19, 1906) gives an interesting review of a rare
case, which occurred in a healthy man, aged fifty-nine. The etiology
was not ascertained. The first symptom noticed was three tumefactions
on the neck : the first about the size of a small orange, situated in the
right lateral region, between the posterior border of the stemomastoid
and the trapezius above the clavicle; the second situated just below the
hyoid, about the size of an tgg\ and the third, a little smaller, on the
left side of the neck. There was some stenosis of the trachea due fo
pressure, which produced dyspnea. Temperature normal; pulse 80.
A vertical incision was made over the central tumor, and the tissues
were all found infiltrated and the trachea involved. Microscopic exam-
ination confirmed the diagnosis. A tracheal canula was introduced,
but it did not relieve the dyspnea. While actinomycosis may involve
different organs, this case seems unique, and the growth might have
been taken for various solid or polycystic tumors.

PROCTOLOGY.

LOUIS JACOB HIRSCHMAN, M. D.

CLINICAX. PIIOPBSSOK OP PKOCTOLOGV IN THB DBTKOIT COLLBGB OF MBDICINB.

NOTES ON TREATMENT OF PRURITUS ANI.

The Medical World for April, 1906, contains the following prac-
tical hints on the very troublesome affection, pruritus ani :

A saturated solution of boric acid, employed as a wash in pruritus
ani, is both a cleansing agent of value, and in many cases a curative
power as well.

366 ORIGINAL ABSTRACTS.

An ointment prepared by thoroughly blending one ounce of lard
and one dram of calomel is a good application in cases of pruritus ani
(Hare).

The internal use of calcium chlorid should not be forgotten in cases
of pruritus ani. It should be given in doses of twenty grains three
times a day, and may be prescribed as follows :
3 Calcium chlorid, 2 drams.

Tincture orange flowers, 6 drams.
Chloroform water, enough to make 6 ounces.
Mix, and direct one or two tablespoonfuls, three times a day.
Smaller doses may have to be ordered if the stomach proves irritable.
These doses often cause an increased thirst. It is best given one hour
after meals.

Cocain, incorporated in ointments, often fails utterly in pruritus ani,
as the fats prevent its exerting its power.

Sodium thiosulphate, one-half dram to the ounce of water, is of
service in certain cases of pruritus ani.

Ringer commends the use of the following ointment in cases of
pruritus ani:

B Acid salicyl, 2 drams.
Ol. theobrom, 5 drams.
Cetacea, 3 drams.
01. myristica, ij^ drams.

DERMATOLOGY.

WILLIAM FLEMING BREAKEV. M. D.

CLINICAL PKOPBSSOK OF DBKMATOLOGY AND ST7H1LOLOGY IN THB UNIVBBSITT OP MICHIGAN.

AND

JAMES FLEMING BREAKEY, M. D.

ASSISTANT IN DBKMATOLOGY IN THB UNIVBRSITY OP MICHIGAN.

A STUDY OF SYPHILIS.

The April number of the American Journal of Dermatology is
devoted to a study of syphilis, and each of its eight articles is worth

reading in its entirity.

* * *

THE SPIROCHMTA PALLIDA OR TREPONEMA PALLIDA.

The opening article by Doctor Edgar G. Ballenger is a fairly
exhaustive resume of the recent bibliography on this subject, with
reports and findings similar to those of Shennan in the March The Lan-
cet and reviewed in the May tbe ^^•uiHn Rnb Surgeon

The author prefers as staining agents azur one, azur two and Gics-
mas eosin, and gets better and darker results by staining three or four
days instead of sixteen to twenty-four hours. Increasing the strength
of solutions did not improve results.

A STUDY OF SYPHILIS. 867

Regarding the spirochaeta, Schaudinn says that the pallida is the
only one having a flagellum at one or both ends.

Robert W. Taylor thinks that the finding of the spirochaeta pallida
in inherited syphilis is the most convincing evidence as to its connection
with syphilitic processes.

Treponema, and no other microbes have been found by Levaditi and
others in the interior of the liver and spleen of stillborn children.

Castellani demonstrated a spiral microorganism in the early lesions
of yaws similar to the treponema pallida, for which he proposes the
name spirochaeta pertenuis or pallidula. The great similarity of this
disease and syphilis makes the observation of peculiar significance.

The deeper layers of the s)rphilitic lesions show the parasite in
larger numbers than does the secretion of the surface. Control tests
have almost always failed to reveal treponema.

Although not established beyond a doubt, nearly all the evidence,
direct and circumstantial, points strongly towards the treponema pallida
as the cause of syphilis.

4( * *

THE DIAGNOSTIC VALUE OF THE SPIROCHMTA PALLIDA IN SYPHILIS,
Doctor George M. Mackee concludes this article with the following
propositions :

(i) The spirochaeta pallida has definite morphological character-
istics.

(2) It is constantly found in primary and secondary s)rphilis.

(3) There is no corroborative evidence of this organism having
been found in any but syphilitic lesions.

(4) The number of organisms found in a lesion is in direct pro-
portion to its degree of infectiousness.

(5) The relation of this organism to syphilis' is in perfect accord
with our clinical knowledge of the disease. For instance, there is no
confirmatory evidence of its having been found in tertiary lesions. It
has been found in the blood in very few instances, while it has fre-
quently been demonstrated in the lymphatic glands, surrounding, and
even in the lumen of the lymph channels.

(6) The spirochaeta pallida has been demonstrated in congenital
S3rphilis by several investigators, both in smears and in sections of the
disseased tissue.

(7) The organism has been followed from man through the apes.

(8) It has also been followed from the primary to the secondary
period of the disease.

(9) In cases of supposed chancres, when the pallida could not be
demonstrated, the patient has subsequently failed to develop secondary
syphilis.

Doctor Mackee uses Goldhom's stain, which has the advantage of
requiring but a few seconds exposure.

368 ORIGINAL ABSTRACTS.

THE STAGES OF SYPHILIS.

Doctor A. H. Ohmann-Dumesnil objects to the classification of
syphilitic processes as primary, secondary and tertiary.

The chancre or primary helcosis is the first symptom of luetic infec-
tion. The terming of this primary syphilis is but a matter, of taste.

Secondary syphilis is a misnomer from the fact that it is not invari-
ably secondary, as confirmed by the presence of iridial gummata in
patients before the appearance of any secondary manifestations.

For this reason the author proposes another and more exact classi-
fication, based upon the pathologic developement of the disease.

Attention is called to the fact that the so-called secondary lesions
are chiefly confined to the cutaneous envelope and are superficial in
character. The one exception being iritis and iridochoroiditis.

In the so-called tertiary manifestations we find that it is the deeper
tissues that are involved, as the periosteum, bones, secretory glands,
and elements of the nervous system and the cerebrospinal axis.

In view of these facts the author proposes the following classifica-
tion: First, the chancre or primary helcosis; second, the stage of
involvement of the superficial epithelial tissues ; and third, the involve-
ment of the deeper and the connective tissue.

INFANTILE SYPHILIS,

Doctor Edward F. Gushing says that statistics of the number of
cases of congenital syphilis among the little patients in the various
Children's hospitals, show that these cases vary in number from one-
half to one per cent. These findings, together with the records of our
Maternity Hospital and Foundlings' asylums emphasize how great is
the early mortality of the disease and how few, comparatively, survive
to an age to come under the observation of the pediatrist or derma-
tologist.

In infantile syphilis proper, as distinguished from fetal and neonatal
syphilis, no definite signs of the disease are apparent at birth. Such
manifestations usually appear in the second month of life, sometimes in
the first month, rarely after the third month.

The various and many manifestations of infantile syphilis are enu-
merated. That the bullous rash should be characteristic of syphilis in
childhood is doubtless due to the loose attachment of the epidermis and
its easy separation from the underlying true skin at this early life. Syph-
ilitic pemphigus is distinguished from nonsyphilitic pemphigus by its
predilection for the palms and soles, by the serosanguineous or purulent
contents of the bullae and the resulting irregular ulcers upon rupture,
and perhaps we shall find by the constant presence of the spirochaeta
pallida in the lesions. Syphilitic coryza and simple acute coryza (with
or without adenoids) must be differentiated, as must also simple derma-
toses and the various syphilodermata. It is here that the finding of the

A STUDY OF SYPHILIS. 368

spirochaeta pallida will be of much value. The physiognomy, the hair,
nails and blood-vessels may all show changes of varying degree. Of
the visceral lesions, those of the liver, spleen and kidneys are of the
greatest importance for diagnosis. Orchitis is not rare, the swollen
testicle showing but little, if any, tenderness. The Roentgen rays may
assist in demonstrating epiphyseal changes in both long and short
bones, or other osseous or periosteal changes.

Feebleness in the newborn or the presence of the "syphilitic wig"
should arouse suspicion enough to lead to search for confirmatory signs
of visceral disease ; or, the problem of an infantile anemia or marasmus
may be solved by looking for an orchitis or splenic tumor.

Thus in all instances of possible or suspected infantile syphilis, the
nostrils should be investigated, the abdomen examined for enlarged
spleen, the testicles palpated, the fingernails inspected, the blood and
urine studied, and perhaps even the Roentgen rays resorted to for aid,
whether or not seemingly characteristic skin eruptions are present.

SYPHILIS IN THE DIGESTIVE TRACT

Doctor Henry Illoway opens this article as follows :
"Though as susceptible to disease as any other part of the human
economy, still, insofar as the specific infection under consideration is
concerned, the digestive tract forms a marked exception. Just as
frequent as are the manifestations of this infection in the nervous
system, so rare, indeed, are they in the organs especially concerned
with the function of digestion. In fact, cases of syphilitic disease of
this part of the organism, indubitably demonstrated as such, are few
and far between."

He reports cases of syphilis, both acquired and inherited, showing
gummata and ulcers of the esophagus, recovering under specific treat-
ment. The stomach is most resistant to the specific pathologic pro-
cesses, succumbing only after such vital tissue changes of the liver,
spleen or other organs as to profoundly impair the nutrition of the
whole organism. For the stomach alone to become the seat of specific
disease is of thie rarest occurrence. Syphilitic gastroenteritis with
recovery under appropriate treatment is reported. The intestines, like
the stomach, are infrequently invaded by syphilis. The forms of mani-
festation are the same in each: (a) Diffuse interstitial inflammation;
(b) gumma (tumor); (c) ulceration with consequent cicatrization;
(d) stricture. Hemmeter divides the diffuse interstitial inflammations
of the intestine into: (i) Acute specific enteritis; and (2) chronic
specific enteritis; both of which conditions, however, are more or less
assumptive. Ulcers, of syphilitic origin, are rarely seen in the stomach
or bowels, and those of the large intestine (the rectum excepted) are
more infrequent than those of the small bowel. The rectum may pre-
sent any of the forms or manifestations of syphilis.

370 ORIGINAL ABSTRAC13.

THE AURAL AND NASAL HISTORY OF SOME SYPHILITIC CHILDREN,

Doctor William A. Dayton mentions first the preponderance of
deaths at birth or shortly after due to syphilis. Hutchinson's three
elements in diagnosis — notched teeth, interstitial keratitis, and otitis
media suppurativa — ^may not be present at all. An editorial in the
Medical Record, August 26, 1893, is quoted as follows :

** Protuberances and hjrperostoses are found at the level of the
epiphyses, especially noticable at the upper extremity of the tibia and
the lower extremity of the radius and ulna. Biit the tibia is the direct
revelation of syphilis. Its form alone will reveal the disease. It is
large, thick, and misshapen, much widened and depressed in its middle
portion. The crest is so much increased in size as to present a plane
face. In general effect the bone is like the blade of a sword. This
conformation is never found in any condition other than hereditary
syphilis, of which it is the pathognomonic sign."

As to local involvement in heriditary syphilis, the parts of least
resistance are the first to surrender. The nasal mucosa shows venous
rather than arterial passive congesticMi, accounting for its bluish appear-
ance. The inferior turbinates may show a white, waxy-looking degen-
eration at the distal end. Such cases, untreated, may show this degen-
erated mass of mucous membrane completely filling the postnasal spaces
by the eighteenth year. In the vault of the pharjmx the coloring is
again significant, the lymphoid tissue will be found rather purplish.
The gummous appearance of the lymphoid growth is the expression of
a syphilitic cervical periostitis and is frequently wrongfully curetted.
Many cases of recurrent "adenoids" may be of specific origin. The
ear is usually the last region to yield to the inroads of syphilis, but once
invaded there is never spontaneous recovery. This occurs, if at all,
only under the heroic exhibition of mercurial . medication. This may
often be preceded to advantage by the use of iodin, and for this purpose
Dayton prefers the plain tincture of lodin to potassium iodid. He com-
bines it with muscilage of salep in the proportion of from one to three
drams of the iodin to three ounces of the salep, the dose of which is a
teaspoonful. He thinks that potassium iodid energizes, if it does not
precipitate, syphilitic coryza. Surgery is contraindicated.

SOME SYPHILITIC AFFECTIONS OF THE EYE AND EAR.
Doctor Sterling Ryerson says no part of the eye is exempt from
syphilitic invasion. It may be affected primarily, when the lesion is
usually found at the conjunctivo-cutaneous border. In the secondary
stage mucous patches may occur on the conjunctiva and ulcerations of
the lids may occur during the tertiary stage. It is the iris, however,
which is the most common seat of ocular syphilis. It is attacked in four
per cent, of all cases (Jules), and thirty to sixty per cent, of iritis is
due to syphilis (Webster Fox). It usually occurs during the first six
months after infection and is rarely painful. The prognosis is favor-

MYASTHENIA GRAVIS. 371

able under proper treatment. Keratitis sometimes occurs in acquired
syphilis. The interstitial keratitis of hereditjiry syphilis usually appears
about the time of puberty. Both eyes are usually affected. Iritis
usually accompanies the corneal inflammation. The duration is from
nine to twelve months. There is usually a permanent loss of vision
short of blindness. Choroiditis and retinitis are late secondary or early
tertiary symptoms. With the opthalmoscope a fine haze may be seen,
but there are usually no large floating opacities in the vitreous. This
fine haze Ryerson considers as pathognomonic of syphilitic retinocho-
roiditis. Prognosis is favorable as regards blindness, though some
defect in vision is sure to occur.

The treatment is the exhibition of mercury. Locally J:he subcon-
junctical injection of cyanide of mercury, atropin, leeches to the temple
and rest of the eyes.

Syphilis may cause atrophy of the optic nerve, more frequently in
connection with locomotor ataxia. The paralytic affections of the
ocular muscles are frequently of syphilitic origin. j. f. b.

NEUROLOGY.

DAVID INGLIS, M. D.

PltOFBSSOR OV NBRVOUS AND MBNTAL DISBASBS IN THB DBTROIT COLLBGB OF MBOICINB.

AND

IRWIN HOFFMAN NEFF, M. D.

ASSISTANT PHYSICIAN AT THB BASTBRN MICHIGAN ASYLUM.

THE CLINICAL HISTORY AND POSTMORTEM EXAMINA-
TION OF FIVE CASES OF MYASTHENIA GRAVIS.

Buzzard (Brain, Autumn and Winter, 1905) gives in detail the
clinical history of the five cases and the autopsic findings are analyzed.
The article concludes with a discussion on the pathogenesis of the dis-
ease. A short bibliography is added. His opinions, as given in his
conclusions, are as follows :

CLINICAL.

(i) That myasthenia gravis is a disease in which the symptoms are
not always confined to the motor symptoms, but may include others of
sensory, mental, or other origin.

ANATOMICAL.

(2) That in all probability it has a definite and constant morbid
anatomy, constituted by the presence of widely distributed cellular, and
sometimes serous exudations (lymphorrhages) in the tissues and
organs of the body.

(3) That slight muscle-fiber changes are frequent and severe mus-
cular atrophy rare occurrences in the disease.

372 ORIGINAL ABSTRACTS.

(4) That proliferative and degenerative changes in the thymus
gland are frequently but not constantly met with.

THEORETIC.

(5) That the symptoms of the disease are best explained by assum-
ing the presence of some toxic, possibly autotoxic agent, which has a
special influence on the protoplasmic constituent of voluntary muscle,
and a less specialized influence on the function of other tissues.

(6) That the relation of this toxin to the incidence of lymphor-
rhages and to thymic alterations is not clear. i. h. n.

THERAPEUTICS.

DELOS LEONARD PARKER, Ph, B., M. D.

UKTUWUI ON MATBKIA MSOICA IN TNB DrTROlT COLLSGB OP MBOiaNB.

COCILLANA As AN EXPECTORANT IN PULMONARY
TUBERCULOSIS.

Doctor George William Norris, of Philadelphia, in a paper with
the above heading (The Therapeutic Gazette, June, 1906), says:

**The employment of expectorants in pulmonary tuberculosis is
justly falling more and more into disuse, their place being supported
by the administration of remedies calculated to correct the digestion
and increase the general tone of the patient's system. Nevertheless,
times occur, especially when a bronchitis or some other acute infection
supervenes upon a tuberculous process, when an expectorant is nec-
essary in order to facilitate the expulsion of an inordinately large
quantity of secretion, and thus allay exhausting cough. Having always
been somewhat skeptical as to the value of the majority of drugs cur-
rently classified as expectorants, I was, notwithstanding, led to try the
administration of the fluid extract of cocillana in a number of tuber-
culous patients, through the cordial indorsement given to this drug by
Doctor E. S. Bullock, of Silver City, New Mexico."

The extract of cocillana is from the bark of the Syco carpus Rusbyi,
a large tree of Bolivia. The physiologic action is said to resemble
somewhat that of ipecacuanha. Besides being an expectorant the drug
is said to have laxative and heart tonic properties. The dose of the
fluid extract is from five to twenty-five drops, which may be repeated
every three or four hours. Full physiologic doses cause vomiting,
purging, sneezing, frontal headache, and nasal discharge.

Doctor Norris studied the effect of the drug in thirty-one cases of
tuberculosis of the lungs. The cases comprised early, secondary, and
advanced conditions of the disease. The drug was administered in
various ways and in various doses. The best results were obtained from
giving five-drop doses of the fluid extract well diluted with water at
intervals of three hours. Complete records were kept. In the thirty-

EARTHQUAKE AND THE DOCTORS. 373

one cases in which it was used marked improvement occurred in seven ;
slight improvement in fourteen; no improvement in eight; and condi-
tion made worse in two. The improvement that occurred consisted most
commonly of a lessening in the viscidity of the sputum with increased
ease in expectoration. Cough as a symptom was but slightly affected.
In one case nausea and vomiting was caused by each administration of
the drug. The patient in which this occurred was suffering from
chronic indigestion. No effect was observed upon the heart and pulse
rate. None of the patients developed sneezing, coryza, frontal head-
ache, or looseness of the bowels. This freedom irom disturbing effects
was doubtless owing to the smallness of the dose.

On the whole, Doctor Norris found that the results were not so
satisfactory as those obtained from the following mixture, which is
largely used at the Phipps' Institute, where the work was carried on:
9 Ammonii chloridi, 4 drams.

Spiritus glonoini, i drop.

Spiritus ammoniae aromatici, i fluid ounce.

Tincture nucis vomicae, J4 fluid ounce.

Elixiris calisayae, q. s., ad. 6 fluid ounces.

Misc. Signa — Dose, one teaspoonful in water.

EDITORIAL COMMENT.

THE SAN FRANCISCO EARTHQUAKE AND THE DOCTORS.

Physicians, as well as others, will be interested in the "earthquake
numbers" of some California medical periodicals. The earthquake took
place while the California State Medical Society was in session in San
Francisco. A number of the Los Angeles profession wrote up their
personal experiences and these were published in the May number of
the Southern California Practitioner, One of the most interesting is
by Doctor Ernest W. Fleming, a graduate of the University of Mich-
igan. Numbers five and six of the Pacific Medical Journal appear in
a single number as the first publication since the disaster. The whole
number is a striking evidence of the catastrophe, the destruction of
property that followed and the undaunted courage and tireless energy
of the Califomians. The Journal has sixty pages of reading matter
and almost as many of advertisements. The brief introductory states
that the entire Journal plant was destroyed ; then follows a concise but
very clear account of the earthquake, with some mention of previous
historic earthquakes; the fire and the ravages caused by it are also
concisely described. More than three-fourths of the city was burned
and three hundred thousand people rendered homeless and without
food and water ; probably as many as one thousand lives were lost ; the

374 EDITORIAL COMMENT.

destruction of property is estimated at $300,000,000 to $400,000,000,
with insurance amounting to less than $150,000,000. The remarkable
spread of the fire is explained by the intense heat in the upper air
igniting the tops of buildings at a great distance from burning houses.
Most of the tall buildings were burned from the top downward. The
air was so hot that it could be felt across the bay, a distance of several
miles, and large fire brands were picked up ten miles from the city.
Window panes were cracked blocks away from the fire. The hospital
of Doctor Winslow Anderson, editor of the Journal, containing one
hundred seven rooms and filled with patients, was very little damaged
by the earthquake. During the course of the fire the patients were
first removed to Doctor Anderson's residence, and sometime afterwards
the former building caught fire and burned down. The fire approaching
the improvised hospital, the patients were moved again to towns across
the bay or to the Presidio hospitals, and the moving was so successfully
accomplished that not one of the patients nor any of the nurses received
the slightest harm. The editorial offices of the Journal were in the
hospital, and a library of several thousand volumes, and this was
entirely destroyed. Much of the damage in various parts of the cit>'
was caused by dynamiting. This did very little in many cases to stop
the spread of the fire, but caused tremendous destruction of private
property. One physician, for example, worked all day burying his
books and instruments. The dynamiters blew up the building. From
the downward tendency by exploding dynamite the buried treasures
were destroyed, but the surrounding houses escaped both fire and dyna-
mite. The heroism of the medical profession is briefly alluded to and
other details of the work after the fire are duly described. Among other
interesting items in the article are those in regard to Chinatown, earth-
quake psychoses, marriages and births after the shock, both of the
latter being unusually numerous. Doctor H. D'Arcey Power has a
short article on the "Psychic Effects of the Earthquake;" the work of
other physicians is described more or less fully. Many personals furnish
information that will doubtless be appreciated by friends of local physi-
cians. Altogether the Journal is a striking monument to the extraor-
dinary and appalling calamity and to the heroism of the men who went
through it. It is one of the most interesting souvenirs that a medical
man could possess.

ANNOTATIONS,

A SCORE FOR RADIUM IN SURGERY.

Some time ago the success of Baird with trypsin in the treatment
of cancer and allied growths was announced in medical literature.
Now, Robert Abbe proposes an entirely different therapeusis for the
treatment of carcinoma, granuloma, lupus, epithelioma, and sarcoma,

SCIENTIFIC ACHIEVEMENTS OF SCHAUDINN. 376

namely, the employment of the rays of radium salts. While Abbe's
experience has not entirely eliminated failure, his success, nevertheless,
with a vast amount of clinical material, has firmly convinced him that
proper apparatus will greatly promote the efficiency of this metallic
agency. In a series of one hundred twenty-seven cases treated by
Abbe excellent results have been reported. In thirty-five cases of lupus
and epithelioma not a single one resisted the ameliorating properties of
the rays, and twenty were pronounced entirely cured. Recurrences
were exceptionally few and healing readily followed secondary admin-
istration of the rays. In internal carcinomata the rays exerted little
effect. Regarding the action of radium salts on warts the investigator
says : **It is of some interest to note at this point that the ordinary
wart, small or large, is but an overgrowth of cells normal to the skin,
and in every case where I have laid a radium tube on one it has speedily
disappeared through a process of retrograde degeneration of the mass
of cells composing it." Abbe classes radium rays as irritating and
stimulative. When the dosage is moderate they are stimulating and
their effect alterative ; on the other hand when the dosage is excessive
they are irritating and their effect destructive.

THE SCIENTIFIC ACHIEVEMENTS OF SCHAUDINN.

The untimely demise of Fritz Schaudinn, at the early age of thirty-
five, removed from the medical world a man whose researches gave
promise of much enlightenment in the field of biology, and especially
in an important branch of that science — bacteriology. The work of
Schaudinn and his confrere, Hoffmann, with various forms of protozoal
life, notably the spirochaeta pallida, throw much light upon certain
pathologic conditions. The determination of the etiologic factor of
syphilis placed a shining crown upon the head of the young investigator
and immortalized his name, but his premature death will probably
delay the discovery of new facts concerning the organism. To Schau-
dinn is due our knowledge of the relationship between protozoa and
metazoa, the former having been classed by scientists as the only ani-
mals to which the blastodermic stage of development is not peculiar.
This theory, however, was discredited and proven erroneous by
Schaudinn. His researches in cytology have exerted marked influence
in establishing a correct understanding of this branch of science, and his
assumptions are in harmony with the latest teaching in this subject.
The observations on sporozoa, trypanosomes, and the spirochaeta have
led to the adoption of new views regarding the methods of propagation
and multiplication of microorganisms. Prospectively this zealous Teu-
ton had much- to contribute to science, and it is to be hoped that some
coworker will be able to grasp the situation and successfully continue the
investigations so auspiciously inaugurated.

876 EDITORIAL COMMENT.

AN APPEAL IN BEHALF OF BLIND ARTISANS.

Miss Helen Keller, in a contribution to the Outlook, bemoans the
indifferent attitude of our government toward the welfare of the blind,
and contrasts our system of succoring such individuals with the meth-
ods vogue in Europe. That this remarkable woman is eminently qual-
ified to discuss the question no one will deny, and her own case attests
the wonderful degree of development attainable under proper direction
and instruction. Statistics compiled by the New York Commission for
the Blind disclose the fact that only one per cent of sightless persons
in the metropolis are employed. In London only six per cent of the
blind are self-supporting, but in the other cities of Great Britain thir-
teen per cent find employment in the workshops. Both France and
England have societies whose purpose is to secure positions for the
blind and arrange for a disposition of their handiwork, while in Ger-
many a similar system under governmental control proffers assistance
of like nature. The chief pursuits open to the blind are mat-weaving,
many kinds of carpentry, massage, brush-making, mattress-making,
and the manufacture of baskets, both fancy and plain. However
apathetic our country has been in the past, an awakening to the neces-
sity of educating the blind along lines that will best subserve their
welfare and maintenance is apparent, Massachusetts, Connecticut,
Maine, Pennsylvania, Michigan, and Wisconsin having at last inaugu-
rated movements in behalf of nature's deficiency.

CONTEMPORARY.

HYPNOTISM : ITS HISTORY, NATURE, AND USE.

[HAROLD M. HAVt, OF THB COLI.K2B OV PHTSICIAMS AND SUROBONS, NRW YORK OTT, IN TMB rOPUUkS

tCIBMCB MONTHLY.]

It is perhaps unnecessary to state that the word hypnotism brings
to the mind of the average person timid recollections of many criminal
acts. That is because few people hear of hypnotism in its proper
sphere. It is clothed with the garb of shame; it is surrounded with
all the horror belonging to the age of witchcraft. Newspapers delight
in depicting its bad sides, in painting to the world the crimes that have
been committed under its influence, the fearful results of its all pow-
erful spell. To most it means a giving up of one's will to another who
is superior, the crushing of one's entity by the power of another, the
total abstinence of individual self-control, the entire weakening of one's
higher intelligence. Vivid imagination supplies the result — ^suffering,
hardship, labor and total subservience.

The question arises, "Why should hypnotism have been thus
derided ?" Simply and plainly because the ignorance of people in gen-
eral has given it no opportunity to show its good sides. Unfortunately
people are always looking for the "eternal gullible" and are not satisfied

HYPNOTISM. • 377

until they get a taste of it. And as hypnotism was first practised solely
and is now practised mostly by men who have made the world their
dupes, the world has had to suffer in the advancement of hypnotism on
a scientific basis. But it has been so with other sciences. Astrology
and alchemy are now things of the past ; but astronomy and chemistry
are their results — two great and everlasting sciences. There is there-
fore still great hope for hypnotism ; for, although known under differ*
ent names for so many hundreds of yeai«, it is still in its infancy and
the scientific aspect of the subject is yet in embryo.

Before, however, proceeding to cases in point, we may review
briefly the history of hypnotism up to the present day. Call it what
we may, since the beginning of the world, before Noah ever went on to
the Ark or the whale swallowed Jonah (much to the discomfort of
both), hypnotism has been practised. The influence of one man over
another by a certain innate quality or by personal magnetism has
always been. Even Eve exerted an influence over Adam which has
precipitated the world into misery and kept it there ever since. As
time went on, people recognized this influence, gave it a name and
called it the influence of the gods, the result being that those who were
ordained with this wonderful power were called God's ministers. Sooth-
sayers, divine healers, the oracle ministers, all made the oriental people
construe this power by religious means. Among the Chaldeans, Baby-
lonians, Persians, Hindoos and other ancient peoples, there were priests
who, because of their power of exerting a superhuman influence over
others, were considered divine. To this day the vogis and fakirs of
India use this power and throw themselves into a state of hynotic
ecstacy and revery. In the eleventh century it was used in the Greek
church, as it is now by the omphalopsychics. In the middle ages it
was practised by ' Paracelsus, who maintained that the human body
possessed a double magnetism, the first magnetism coming from the
planets, the second from flesh and blood. All through the middle ages,
hypnotism was practised under different names such as witchcraft,
divinations, et cetera. It was supposed to be a supernatural power
derived from Satan himself, and, therefore, the user of this power was
expelled from society and sometimes put to death. Magic spells where
people went into trances or out of their head were of common occur-
rence. Religious ecstasy, demon-possession, cures by shrines and relics,
the cure by the king's touch, et cetera, were all phenomena of this sort.
During the seventeenth century, a number of faith-healers sprang
up all over the continent and British Isles. Many of these men were
noted for their skill, but the one who attained the greatest reputation
was one by the name of Greatrakes, who was born in Ireland about
1628. This "healer" was sent for by a Lord Conway who expressed
his message in the following language : "to cure that excellent lady of
his, the pains of whose head, as great and unparallelel as they are, have
not made her more known or admired abroad than have her other endow-

378 KUITORIAL COMMENT.

ments." At Lady Conway's was a miscellaneous gathering, chiefly
engaged in mystical pursuits, **an unofficial but active society for
psychical research, as that study existed in the seventeenth century."
Says Mr. Lang: Greatrakes' special genius in these mystical pursuits
was of divine agency ; for he tells us that at one time "he heard a voyce
within him (audible to none else), encouraging to the tryals: and
afterwards to correct his unbelief the voice aforesaid added this sig^,
that his right hand should be: dead, and that the stroaking of his left
arm should recover it again, the events whereof w^ere fully verified by
him three nights together by a successive infirmity and cure of his arm."
We are told that he failed to cure the lady but that he worked some
wonderful miracles of healing among the sick of the neighborhood.

Henry Stubbe, a physician of St rat ford-on- Avon, thus comments
on Greatrakes' miracles. He says "that God has bestowed upon Mr.
Greatrakes a peculiar temperament, et cetera, composed his body of
some particular ferments, the effluvia whereof, being sometimes intro-
duced by a light, sometimes by a violent friction, should restore the tem-
perament of the debilitated parts, reinvigorate the blood and dissipate
all heterogeneous ferments out of the bodies of the diseased, by the eyes,
nose, mouth, hands and feet." Indeed, he recognized the difference
between functional and organic complaints ; and he only meddled with
such diseases as "have their essence either in the masse of blood and
spirit (or nervous liquors) or the particular temperament of the part
of the body" and attempted to cure no disease "wherein there is a decay
of nature." "This is a confessed truth by him, he refusing still to
touch the eyes of such as their sight has quite perished." None the
less his cures were regarded as miraculous, and Doctor Stubbe tells us
that "as there is but one Mr. Greatrakes, so there is but one Sonne" ;
Greatrakes' method consisted principally in stroaking and passings and
in driving the pains from one point to another until they went out at
the fingers or toes.

In the latter half of the eighteenth century many fakirs, alleged phil-
osophers, quacks and cosmongerers came to the front. Swedenborg,
with his inspirations; Cagliostro, with his idea of personal power;
Schrepfer, with the beginning of spiritualism; and then Gassner, the
priest healer, w-ho gave to Mesmer later on some of the ideas for the
foundation of his theories.

Johann Joseph Gassner, a Swabian priest, appeared upon the scene
in 1773. He was a forerunner of our modern spiritualist in a way, but
had the added distinction of attributing all diseases to the devil. So
his object was to pray for the expulsion of this satanic being. The
patient had to have implicit faith and was made to give a detailed
account of his malady. Gassner's next procedure was to chant various
symptoms such as pain, weakness, stiffness, et cetera, and at his per-
emptory command to "stop," these symptoms would disappear and the
patient be well again. At the words "You will cease being disabled,"

HYPNOTISM. 379

the patient's symptoms vanished. "Your right hand and arm will
become somewhat weak," he says ; and no sooner are the words out his
mouth than the right hand is cold and numb and the pulse is acceler-
ated. "Your left hand will become as your right one was and this one
will be normal," is his next invocation, whereupon the left hand is cold
and numb and the right returns to normal. Gassner keeps up these
incantations until the patient is entirely cured, each prayer being accom-
panied by the invocation that "this- is accomplished in the name of the
Lord, Our Father." Gassner's cures in theory and practise were
identical with those of Greatrakes, except that the mystery was now
clothed in a religious garb. In both, the predominant idea was the
suggestion to the patient that he would get well.

The reason why hypnotism was not studied scientifically until the
middle of the eighteenth c^tury was that there was too much of an
air of mystery surrounding the workings of the phenomena. When-
ever hypnotic power was discovered in a person, he at once considered
himself as one who possessed attributes which placed him above the
plane of society. Suggestion was of course practised as it always has
been, but the true idea of what the power consisted of was unknown.
At last, toward the close of the century, Frederick Anton Mesmer rose
before the world as a disciple of a new force which was destined to turn
the scale on to the side of science and forever after to present hypno-
tism in a new light.

jFrederick Anton Alesmer was born at Weil, near the point at which
the Rhine leaves the Lake of Constance, on May 23, 1733. He studied
medicine at Vienna under eminent masters, although at first his parents
had destined him for the church. Interested in astrology, he imagined
that the stars exerted an influence on beings living on the earth. He
identified the supposed force first with electricity and then with mag-
netism; and it was but a short step to suppose that stroking diseased
bodies with magnets might effect a cure. In 1776, meeting Gassner in
Switzerland, he observed that the priest effected cures without the use
of magnets, but by manipulation alone. This led Alesmer to discard the
magnets, and to suppose that some kind of occult force resided in
himself by which he could influence others. Mesmer's first practical
work with magnets was in 1779, when he magnetized a young lady
complaining of various functional disorders. This emotional young
lady "felt internally a painful streaming of a very fine substance, now
here, now there, but finally settling in the lower part of her body and
freeing her from all further attacks for six hours." She was extremely
sensitive to any of Mesmer's suggestions, but would obey no one but
him. Thus we see the primeval workings of animal magnetism, after-
wards called hypnotism.

Mesmer removed to Paris in 1778, and in a short time the Fiench
capital was thrown into a state of great excitement by the marvelous
effects of what he called mesmerism. Mesmer soon made many con-

380 EDITORIAL COMMENT.

verts; controversies arose; he excited the indignation of the medical
faculty of Paris, who stigmatized him as a charlatan; still the people
crowded to him.

While at Paris his practise became so enormous that it was impos-
sible for him to handle all his patients. So he invented a scheme by
which a number of his patients could be magnetized at once. He had
troughs filled with bottles of water and iron filings, around which the
patients stood holding iron rods which issued from the troughs. All the
subjects were tied to each other by cords so that they could not break
away and thus spoil the contact. Perfect silence was necessary and soft
music was heard. The patients were affected variously, according to the
suggestion Mesmer gave them. Some became hysterical, others crazed,
some became affectionate and embraced each other, while others laughed
and became repulsive. This lasted for hours and was followed by states
of dreaminess and languor. A picture given by Binet and Feret. two
eminent French scientists, will present an idea of these meetings.

''Mesmer, wearing a coat of lilac silk, walked up and down amid this
agitated throng accompanied by Deslon and his associates whom he
chose for their youth and comeliness. Mesmer carried a long iron
wand» with which he touched the bodies of the patients, and especially
the diseased parts. Often laying aside the wand, he magnetized the
patients with his eyes, fixing his gaze on theirs, or applying his hand to
the hypochondriac region and to the abdomen. This application was
often applied for hours, and at other times the master made use of
passes. He began by placing himself *en rapport' with his subject.
Seated opposite to him, foot against foot, knee against knee, Mesmer
laid his fingers on the hypochondriac region and moved them to and
fro, lightly touching the ribs. Magnetism with strong electric currents
was substituted for these manipulat^ns when more energetic results
were to be produced. The master, raising his fingers in a pyramidal
form, passed his hands over the patient's body, beginning with the head,
and going downward over the shoulders to the feet. He then returned
to the head, both back and front, to the belly and the back, and renewed
the process again and again until the magnetised person was saturated
with the healing fluid and transported with pain or pleasure, both sen-
sations being equally salutary. Young women were so much gratified
by the crisis that they wished to be thrown into it anew. They followed
Mesmer through the halls and confessed that it was impossible not to
be warmly attached to the person of the magnetizer."

Mesmer was not an imposter by any means. He had deceived him-
self and had thus deceived others. But the Academy of Sciences in
Paris believed that he was a mystic and a fanatic, and made it so hot
for him that he was finally forced to leave France, where, however, he
returned later. He died in 1815, and for a time animal magnetism fell
into disrepute and Mesmer was denounced as an imposter.

Before Mesmer's death, he moved irom Paris to a secluded spot
among the hills. We see him at the last — ^bitterly complaining of the

HYPNOTISM. 381

treatment he had received, thoroughly convinced as to the truth of his
pet theories, performing various cures for the peasants about him, and
living the simple life of a hermit.

Throughout Mesmer's career, the streets were not paved with gold.
Many people died under his treatment, giving the belief that the treat-
ment itself was the cause of death. He was treated with ridicule
wherever he went. Papers, plays, et cetera, brought him even more
prominently before the public in a more ridiculous light than his own
hypothetical and mystical performances. A comedy, "Docteur Mod-
ernes" brought his procedures on the stage. It severely criticized his
"fanatical" enthusiasm for a quondam science and portrayed the sup-
posed abuses of his treatment. In England notices like the following
appeared in the leading journals :

"The Wonderful Magnetical Elixir. Take of the chemical oil of
Fear, Dread and Terror, each four ounces ; of the Rectified Spirits of
Imagination, two pounds. Put all these ingredients into a bottle of
fancy, digest for several days, and take forty drops at about nine in the
morning, or a few minutes before you receive a portion of the magnetic
Effluvia. They will make the effluvia have a surprising effect, et cetera.

Once, in 1785, a mock. funeral oration upon Mesmer took place,
making his exhibitions and theories seem more ridiculous than ever.
Thus he was tossed about between ridicule and praise until, as we have
seen, his life was hardly one of harmony or joy.

BRAID.

Although a number of men followed Mesmer, appropriating his
method, enlarging* upon it and changing it somewhat — such mon as
de Puysegur — it will be impossible in such a brief essay to tell of all
of them. However, there is one man who rose up in the chaos of the
times and again added new facts and theories to the science. This
man was Braid, a surgeon of Manchester, England. Braid was born
in the year 1795 on his father's estate in Fifeshire. He received his
education at the University of Edinburgh, later being apprenticed to
Doctor Charles Anderson, of Leith. After graduating, he was appointed
surgeon to the Hopetown mining works in Lanarkshire, after moving
to Dumfries, where he engaged in practise with a Doctor Maxwell.
An accident happening at that time brought to his town a Mr. Petty,
who finally persuaded him to move to Manchester. It was here that he
carefully worked on his new discovery and practised his cures. He
died on March 25, i860.

There is very little in Braid's life of especial interest, except his
investigations in animal magnetism. His life seems to have been par-
ticularly free from the early struggles of a young practitioner. His
interest in animal magnetism dates from the time he witnessed a seance
by a M. Lafontaine, a traveling mesmerist. He was extremely skepti-
cal, but this one urged him to try experimenting himself.

[to bb continukd ]

382 MEDICAL NEWS.

- MEDICAL NEWS.

THE AESCULAPIAN GRIST AT ANN ARBOR.

The following received the degree of Doctor of Medicine at the late
commencement exercises of the University of Michigan : Elmer Good-
man Balsam, Robert Hause Beach, A. B., Frederick Beekel, A. B.,
Gordon Berry, A. B., Joseph Tower Berry, B. S., Elton Pope Billings,
A. B., Richard Arthur Bolt, A. B., Fritz Albert Brink, Eugene Taylor
Brunson, A. B., William Sanders Chapin, A. B., Leroy William Childs,
A. B., Frederick Earl Clark, Herbert Everett Coe, A. B., Anna Marion
Cook, George Henry Crary, Marshall Lawrence Cushman, Charles
Carroll Demmer, David Lewis Dunlap, B. S., Norma Bertha Elles,
Ralph David Engle, A. B., Lemuel William Famulener, Ph.C, A. B.,
Myron Stephen Gregory, Edward Goodwin, Hilbrand J. Hards, John
Frank Hastings, John Francis Hincks, Lester Orlo Houghten, Lloyd
Watterson Howe, Ivan Lewis Hunt, David Sanders Jickling, Catherine
Johnston, B. S., Harrie W. Kenfield, Guy Almeron Klock, Don DeWitt
Knapp, A. B., David J. Levy, A. B., Frank Adam Mcjunkin, Fraley
McMillan, A. B., Frank Noble Martin, George Washington More, John
Walter Needles, A. M., D. D.S., Roscoe Charles Olmstead, A, B., Frank
Joseph Parizek, Paul Morse Patterson, Esther Kempton Payne, Alvin
Roy Peebles, Frank Qeveland Pennell, A. B., Charles Arthur Peterson,
Eryl Smith Peterson, John Hibbard Pettis, A. B., Julius Henry Powers,
Jr., A. M., Lewis D. Remington, Walter Henry Rieger, Orville Rock-
well, Fred Schoepfle, Jr., Royston Earl Scraflford, Lucetta Amelia
Smith, John William Snyder, Arturo Torregrosa, A. B., Chad Adelbert
Van Dusen, Dell Warner Ward, A. B., John Taylor Watkins, Anna
Weld, Ray Close Whitmore, Carl John Wiggers, William G. Winter,
Frank Clarence Witter, Walter Stuart Woodruff, James Anderson
Work, Jr., A. B., Hessel Sjoerd Yntema, A. B.

MINOR INTELLIGENCE.

Typhoid fever has developed at the United States Military
Academy, several cases having recently been reported.

Of the one hundred seventy-one slaughter houses in Philadelphia,
thirty-seven have been condemned by the Bureau of Health, because of
unsanitary conditions.

Columbia University recently conferred the degree of Doctor of
Science on Baron Kanehiro Takaki, M. D., F. R. S. C, Surgeon-
General of the Japanese navy.

Berlin has a society for the study of the history of the sciences and
of medicine. The president is Imperial Privy Councilor von Buchka,
and the vicepresident is Professor Paget.

MINOR INTELLIGENCE. 383

Ipswich, South Dakota, is in the throes of an epidemic of typhoid
fever. Over one hundred persons contracted the disease at a picnic as
a result of drinking lemonade, the water for which was procured from
an abandoned well.

Doctor G. Frank Lydston, the well-known author, of Chicago, is
shortly to issue another novel entitled *Toker Jim." The story depicts
the characteristics of the early American frontier type, and will undoubt-
edly be of great interest.

A Brooklyn mother has recently given birth to her twenty-first
child. Eleven of the children have been females and ten males, and of
this total seventeen survive, making what is conceded to be the largest
family in Greater New York.

The first person to receive the degree of Doctor of Medicine in
North America was Daniel Turner. The degree was an honorary one
and was conferred by Yale College in 1720, as a mark of esteem for the
financial aid he had tendered the institution.

Twenty nurses recently became ill with ptomain poisoning at Belle-
vue Hospital, as a result of eating canned tongue and ham. In justice
to the institution it should be said that the prepared food was not from
the hospital larder, but had been brought in \>y the nurses.

The New York Postgraduate Medical School and Hospital is the
recipient of a gift of $5,000 from Mr. and Mrs. Edgar E. Brandon, of
Oxford, Ohio. The sum is to be utilized in the establishment of an
obstetrical ward in memory of the infant son of the donors.

Articles of incorporation have recently been filed for the College
of Physicians and Surgeons of Little Rock, Arkansas. The new insti-
tution will open its doors on October i, in the old Maddox Seminary
Building. The president of the college is Doctor C. R. Shinault.

A Physicians' Club was recently organized by the physicians of
Escanaba, Michigan. A schedule of fees was adopted and the follow-
ing officers elected: President, Doctor A. F. Snyder; vicepresident,
Doctor H. B. Reynolds; secretary. Doctor H. W. Long; treasurer,
Doctor J. D. Groos.

Through the generosity of Doctor Eugene F. Cordell, Professor of
the History of Medicine and librarian of the Medical School of Mary-
land University, that institution is to receive the Miltenberger collection
of nine hundred forty-six volumes, making a total for the library of six
thousand two hundred eighty works.

The substitution of paper handkerchiefs for the linen article is being
agitated in London, where the argument is advanced that their employ-
ment will inhibit the dissemination of tuberculosis and other infectious
diseases. In many English sanatoria paper handkerchiefs have already
been adopted. Receptacles are provided for their disposition and sub-
sequently they are burned.

3B4 MEDICAL NEWS.

Toronto, Ontario, has been converted into a medical mecca during
the month of August. From the 2ist to the 25th the British Medical
Association was m session; on August 19 the American Orthopedic
Association assembled; and on the following day the Ontario Medical
Association convened its annual meeting.

A NOVEL patient was presented for treatment at Bellevue Hospital a
short time ago, in the person of a monkey, whose left forefoot had been
fractured in a fracas with the cook, on whose ship he was mascot. A
plaster cast was applied under ether anesthesia and conditions augur
well for the complete recovery of his monkeyship.

Twenty-seven cases of variola are reported from the Isthmus, all
the victims being negroes. The disease is principally confined to the
City of Colon, the remainder of the Canal Zone being practically
exempt. No American has yet contracted the malady and no deaths
are reported from existing cases. This is the first outbreak of smallpox
since the American invasion.

Report says that the w^fe of Wu Ting Fang, former Chinese min-
ister to Washington, has subjected herself to a surgical operation wuth
the hope of restoring her deformed feet to their natural symmetry.
Many Chinese women have resorted to like procedure, and the prob-
ability obtains that the abominable practice of foot-binding peculiar to
the C)rientals will be discountenanced in future.

The free alcohol bill was passed by the senate on May 23. This
permits of the employment of grain alcohol in the arts and for com-
mercial purposes without payment of internal revenue tax. The pass-
age of this bill is to be commended, since the followers of pursuits
requiring constant contact with wood alcohol were frequently subjected
to great discomfort, sometimes even loss of eyesight or fatal illness
resulting.

The first American law distinguishing between physicians who were
graduates of some college of medicine and those who had no diploma,
was passed in Virginia in 1736. It provided that "those persons who
have studied physic in any University, and taken a degree therein,*'
might charge whatsoever fee they desired, while "surgeons and apothe-
caries who have served an apprenticeship to those trades" must charge
a lower specified fee.

Municipal control of the practice of medicine is vogue in Zurich.
The council of that city, having successfully regulated hygienic
conditions, now essays to retain only forty physicians, whose salary
will be £500 per annum, and who must tender, gratis, treatment alike
to rich and poor. Since Zurich has a population of on,e hundred twelve
thousand inhabitants it would seem that the medical staff is inadequate,
and hence the success of the venture will be awaited with interest.

A PROFESSIONAL MEDICAL JOURNAL.

VOLUME XXVIU. SEPTEMBER, 1906. NUMBER IX.

ORIGINAL ARTICLES-

MEMOIRS.

THE UNSUSPECTED PARASITIC ORIGIN OF MANY
DERMATOSES.*

WILLIAM F. BREAKEY, M. D.

CUNICAL PBOFBaSOK OF DBKMATOLOGT AND STPRILOLOCV IN TMB UMIVBBSITT OF MICHIGAN.

The range of dermal affections due primarily to parasitic causes
is constantly widened by investigations in dermatology of the human
race and by the study of parasitic disease of the lower animals, the latter
conducted in this country by the Bureau of Animal Industry, and
abroad by similar governmental commissions. Such supposedly simple
conditions as seborrhea, acne, and alopecia areata are now held by
reputable — we may say eminent — ^authorities to be caused by definite
parasites. Eczema, which has held domain in literature oyer a wide
group of variable conditions, is being parceled out into various forms
of dermatitis and their complications. And these many times are
shown to be the result of primary parasitic infection. The same may
be said of ecthyma, impetigo, sycoses, dermatitis, and is conceded in
furunculosis, and in many conditions exciting pruritus.

Among other interesting items of Doctor Senn's recent lettersf
while with Peary in Greenland and farther north, and showing the
wide range of his observations, he mentions the fact that birds infested
with vermin in the Arctic region are carriers of pathogenic germs,
either in feathers or. intestinal discharges, or both. A cutaneous affec-
tion ha^ long been known to attack domestic fowls — poultry, pigeons,
and sometimes geese, — to which the names of cutaneous psorospermosis
and molluscum contagiosum have been given. It chiefly affects the
head, and consists of more or less numerous round or oval yellow,

♦Read at the Ann Arbor meeting of the First Councilor District Medical
Society, December 22, 1905.

-f Journal of Cutaneous Diseases, 1904-

386 ORIGINAL ARTICLES.

salient nodules. Diphtheria is an ordinary complication of this affec-
tion in birds and is often mistaken for it. This disease of birds is
contagious frcxn one to another, and there is much reason to believe it
is communicable to man. Like the molluscum contagiosum of man
this affection of birds closely fesembles Paget's disease of the nipple
in its early stage. These affections of man are caused by parasitic
coccidia. The subject is still in the domain of preliminary study.
Doctor Bowen, of Boston, reported last year a case of acute pemphigus
attributed to infection from an epizootic of so-called foot and mouth
disease. The fact mentioned, that the infection from the lower animals
is attended with more severe and disabling symptoms than when
infected from human source, makes it more important that the condition
be early recognized and treated before the infection reaches the deep
tissues and phlegmon and suppuration occur. It is important also to
differentiate between pure dermal affections, whether due to parasitic or
other causes, and exanthemata or other skin lesions, which are but the
outward expression of systemic disease.

Something over a year ago several cases — private and hospital — •
of parasitic sycosis communicated from cattle, brought to me through
inquiry and correspondence reports of a large number of similar cases
in this and other states, and I made a hurried preliminary report of
some of them before the American Dermatological Association in
June, 1904. The occurrence in the winter and spring of the present
year of numerous identical cases, together with the extent of territory 1

in which this and other communicable diseases from domestic and other |

animals to man was prevalent, led me to believe that it was more |

deserving of study and medical notice, and perhaps of more care from
public health authorities, than it had heretofore received. The cases j

re[X>rted in 1904 represented but two families in different counties, at I

a distance of twenty miles or more from each other, but a dozen or !

more patients became infected in these families and their neighbors.
The first patients coming to me — young men — had each been caring |

for and handling cattle affected with a disease of the skin and hair,
the herds having been infected in one case by an infected animal bought
from a drover, and in others by animals from neighboring herds on
roads or across line fences. Several of these patients were disabled
for weeks with deep nodular pustules and burrowing abscesses of the
kerion type. In the cases reported a year ago I was unable, for lack of
time, to demonstrate by culture tests the identity of the parasite found
on the animals and on the men. In the cases coming under observa-
tion in March and April last, the tinea was demonstrated microscop-
ically in the face and hairs of the patient, as well as in the scrapings of
the skin and hairs from the infected animals, and by maceration of
samples of the scrapings and incubation on bouillon media, a culture was
obtained demonstrating the mycelia and spores of the megaloendo-
thrix sporon, from which in turn a guinea pig was antiseptically
inoculated, producing a typical ringworm lesion, the hairs from

PARASITIC ORIGIN OF MANY DERMATOSES. 387

margin of which microscopically examined showed the typical tricho-
phyton.

The dermatomycoses resulting from vegetable parasites are fewer
in number and form a somewhat distinct group. Neuman says each
dermatophyte exhibits constant characteristics in relation to the disease
it induces, and has received a particular name. It is undoubted — so far
as dermatology is concerned — that each dermatophytic species preserves
its autonomy — ^the fungus that is derived from favus never produces
anything but favus ; that of tinea tonsurans has never yielded anything
else than a trichophyton; and all endeavors of cultures to obtain th^
transformation of these fungi into true moulds have been unsuccessful,
while the results of application of moulds to the human skin are super-
ficial and symptomatically analogous to the thie dermatomycosis.

Tinea tonsurans is a parasitic and contagious cutaneous affection
caused by fungi belonging to the genus trichophyton, and which affects -
the ox, horse, cat, goat, sheep and pig as well as man, young animals
being much more susceptible. Infection sometimes ends spontaneously.
Cleanliness and grooming — as in the better kept horses — facilitate
recovery. Shedding the coat expedites recovery, as does removal from
infected stables to outdoors, and the opportunity to roll in dry earth. It
may extend to all animals on a farm or in a stable, or in a regiment,
and also to the people who attend upon them, and it is therefore impor-
tant to promptly diagnose and treat the condition.

Trichophytosis in man, derived from animals, is generally more
acute and severe than it usually is when communicated from man.
Contagion of tinea occurs not only between animals of the same species,
but also between animals of different species, and from animals to man
and from man to animals. The number of such recorded observations
would take too much space to mention separately. The communication
of the trichophyton from horned cattle was observed as early as 1820,
while discovery of the transference to horse, dog, cat, et cetera, is more
recent. The infection is conveyed by direct contact in handling ani-
mals, as pet dogs, cats, in milking cows, grooming horses, and through
the media of halters, harness, combs, brushes, saddles, et cetera. The
spread of the disease is more active in moist, warm conditions of
atmosphere. Gerlier describes an epidemic that began at Forney among
the children of a horse clipper who had cut their hair with his clipping
machine. I have observed the trichophyton in several young men who
liad/Used in common the same face mask in fencing, and in other cases
where the same locker for clothes in a gymnasium had been used with-
out disinfection. The acarus is sometimes a carrier of trichophyton
also, thus causing a double infection.

It is seen that the trichophyton will accommodate itself to very dif-
ferent organizations ; and because of this fact Longuet asks if it might
not be admitted that the trichoph\'ton of man is always of animal
origin — just as many dermatologists are inclined to believe that the
favus of the mouse is the primary source of favus of children. It is

388 ORIGINAL ARTICLES.

Strongly probable, he says, that the original soil of the trichophyton is
the ox, that from this animal it is transferred to the horse when they are
in pasture or stable together, and that from it man more or less directly
receives his tinea tonsurans. The behavior of the lesion, and its frequent
inflammatory character — ^in the case of contagion from animal to man —
appears to be pathognomonic of a parasite in its first cultivation — ^that
is, immediately derived from the cow or horse.

Megnin and Bazin think the trichophyton is not always the same
species in the ox and horse, and instances the fact that the trichophyton
of the ox vegetates more especially in the hair follicles and the epider-
mic layers, causing inflammation of the derma and shedding of the
hairs, while that of the horse passes into the hair itself and renders it
friable and breaks it up. But while it is shown that the malady does
not manifest itself alike in every animal this does not offer an argu-
ment against the identity of the parasite. The difference — ^as in larger
vegetable growths — ^may be due to the soil and environment. Gerlach
showed long ago that in the ox the dark colored hairs break, while the
white ones rarely do so.

As to the vitality of the parasite, Gerlach undertook some experi-
ments to determine the duration of the germinative faculty of the
spores, and found that crusts more than three months old had lost their
potency when placed on an unprepared skin, but spores six months old
still germinated, and produced perfectly developed, ringworm when
inoculation was done by scarification. Megnin successfully inoculated
a dog with crusts eighteen months old. Thin, in making some inter-
esting experiments with cultures of the trichophyton in Koch's nutrient
gelatin, found the spores of trichophytic hairs dead after immersion in
water eight days, but they survived two days' steeping. They preserved
their germinative power after forty-eight hours in olive oil, lard, or
vaseline, while an hour's contact with soft soap or a one-per-cent solu-
tion of acetic acid appeared to be sufficient to kill them. A one-per-cent
solution of sodium carbonate was less efficacious, germination taking
place in three days. Sulphur ointment had slow action upon them and
required several hours to sterilize spores. Citrine ointment was an
active destroyer; after an hour's contact with it spores would not
germinate. On the other hand oil was wholly inefficacious as after
eight hours' immersion in it the trichophyton preserved its vitality.

Tinea favosa, caused by It fungus — ^the achorion schoenleinii — affects
man, the cat, mouse, dog, rabbit, and fowl. It is communicable from
all these animals to each other, and is the severest of all forms of
tinea, as well as the most persistent, by reason of burrowing infection of
deep tissues, and suppuration and complications of dermatitis.

A careful inquiry as to history and occupation of patients will often
aid in diagnosis, and early treatment greatly expedites a cure.

Treatment contemplates cleanliness, parasiticides — without needless
irritants, — ^persistence.

ACUTE MENINGITIS OF NASAL ORIGIN, 38i

ACUTE PNEUMOCOCCIC CEREBROSPINAL MENINGITIS

OF NASAL ORIGIN: REPORT OF CASE, WITH

AUTOPSY.

HUGO A. FREUND, A. B., M. D.

ntLtt AaSISTAMT IN IMTBRNAI. MBDICINB AT THB UNIVBItSITT. OF MICHIGAN.

It is not uncommon to see from time to time cases of cerebrospinal
meningitis in the smaller inland towns and in the rural districts. Par-
ticularly is this so when an epidemic is progressing in the larger cities.
The past two years has witnessed the scourge of this disease in some of
the eastern cities, and with its advent opportunity was afforded for a
considierable amount of useful research with reference to its contagious-
ness, its source, and its mode of infection.

The chief infecting agent in the epidemics such as New York city
experienced in 1904 and 1905, where over two thousand five hundred
cases died, has been the diplococcus intracellularis meningitidis of
Weichselbaum. At the last meeting of the American Public Health Asso-
ciation, Doctor W. H. Park dwelt on the infectious nature and the likeli-
hood of contagion of the epidemic form. He stated that during the
first ten days of the infection, one-half of the patients have nasal and
mouth secretions laden with the meningococcus. He cited an instance
• of five attendants whose nasal discharges were badly infected with these
virulent organisms. That this is an avenue of infection in many cases
seems certain.

Goodwin and von Sholly carefully examined a large series of cases
for the diplococcus intracellularis. They found the organism present
in fifty per cent of the patients during the first two weeks of the disease.
In addition ten per cent of the people who came into contact with the
sick likewise showed the presence of the meningococcus. They believe
in early isolation of these cases and insist that it should be kept up
during the first two weeks at least.

Bolduan and Goodwin made a similar study during the New York
epidemic, reaching the same conclusion.

Hare reported an extremely interesting experience arguing strongly
for the contagious nature of the disease. In his case the physician who
had been in constant attendance upon a fulminating case contracted it
himself and soon died. Others in connection with the case, including
Doctor Hare, had tonsillar and slight febrile infections with no further
ill results.

That other cocci rfiay gain access to the meninges by a similar route
and cause an acute meningitis is plausible. In fact they may be
abetted by acute or chronic antrum disease which frequently paves the
way to sinus and meningeal infections. In the crowded districts of
our large cities cases of acute meningitis are always to be found. " The
nature of these is varied, especially as far as the etiology is con-
cerned. Thus in analyzing various health reports one finds that in

390 ORIGINAL ARTICLES.

many of these sporadic cases the pneumococcus, staphylococcus and
streptococcus! play a not inconsiderate role. Spinal puncture has
given us invaluable aid of late years in determining the nature of the
infecting agent. In consequence many cases have been reported singly
and in groups during the past few years emphasizing Weichselbaum's
well founded assertion, that the diplococcus intracellularis menin-
gitidis was not the sole cause of acute cerebrospinal meningitis.

Eisner, in speaking of sporadic cases occurring in the State of New
York, finds that the pneumococcus is occasionally the cause. The
infection is usually of a malignant nature and early death is the rule.

Willson reports four cases due to the pneumococcus. He lays
especial stress on the similarity of symptoms to the fulminant type in
the epidemic form.

Cupler observed three cases of "primary cryptogenic pneumococcus
meningitis." One case was chronic while two were malignant.

Councilman, in fifty-eight autopsies, discovered primary pneumo-
coccic meningitis in but one instance. He reports^ four cases since
1898 in which the spinal fluid showed the pneumococcus. Each case
was rapidly fatal. "All my experience," he says, "leads me to .the
belief that with rare exceptions cases of primary meningitis are due to
the diplococcus intracellularis meningitidis."

In England, where epidemic cerebrospinal meningitis is uncommon,
the infecting agents are varied. A smaller proportion of the cases are
therefore classed under the group caused by the diplococcus intracellu-
laris. Barras speaks of the rarity of primary pneumococcic infections.
He reports the case of a boy of five years — perfectly well on one day —
who developed, the following morning, intense headache and incessant
vomiting. The headache and spasms which followed were replaced by
coma within forty hours. Death occurred on the fifth day.

These few examples are cited to show that sporadic cases are fre-
' quently caused by the pneumococcus primarily, that the form due to
the meningoocccus, as Willson and others point out, is of the epidemic
variety. Consequently it is of the utmost importance that a diagnosis
be made between the varieties of acute primary cases so that both
proper therapeutic and preventive measures be instituted by the physi-
cian in charge.

It is in this connection that I desire to report to you a case of more
than usual interest. A young unmarried woman, aged twenty-one,
had come from New York City to Ann Arbor on June 15, 1906, for a
visit. Her occupation was that of teacher in the New York slums
where she was constantly in contact with Italians. According to her
mother's statement no disease other than measles had existed in that
neighborhood for some time. (This is contrary to the New York
health report which shows meningitis to have been very prevalent in
that district in the spring of 1906.) The patient had always enjoyed
moderately good health. She had had measles in girlhood. From early
childhood she had suffered from "catarrh" which became "offensive"

ACUTE MENINGITIS OF NASAL ORIGIN. 391

later on. Her nasal condition was under constant treatment for many
years with but transient periods of improvement. Those in attendance
said that the condition was incurable for the "disease was lodged in the
bone of the head." She left New York on June 15 feeling well except
for a slight cold which passed away the following day. About noon of
the 17th her right ear pained slightly and felt "full." She called on a
local physician in whose office she fainted without any examination or
treatment of the ear having been attempted. The following day she
called again when local irrigation and cleansing relieved her consider-
ably. Until Wednesday, the 20th, the young woman was not discom-
fited in any way, her time being spent out of doors and with friends.
On that day she vomited three times, but felt well otherwise. During
the following night she complained of a violent headache and slept
little. She continued to complain of the headache until noon of the
22nd, when she fell asleep. A physician was called at noon, but not
caring to awaken her returned later in the day. When he arrived the
patient was in an unconscious state. He immediately sent her to the
Otolaryngologic Clinic of the University Hospital, thinking that some
process beginning in the ear had extended into the brain cavity.

The patient was first seen in the Medical Clinic as a case referred
by Doctor Canfield. Her condition was as follows at 8 :30 p. m. :
Patient was lying on her right side, head retracted, shoulders thrown
back, lower part of trunk curved forward, legs flexed on thighs and
thighs drawn up to the abdomen. Her forearms, too, were flexed and
resisted attempts to straighten them. Her color was good, cheeks but
moderately flushed and face expressionless. She did not respond to
questions but resisted any forcible attempts to move her from her
fixed position. Temperature by axilla, 103.6° ; pulse, 102 and regular ;
respiration, 22, and quiet.

When patient was placed in dorsal position she groaned occa-
sionally. Her eyes were sensitive to light; the pupils reacted very
slightly. Slight divergent strabismus was present. There were no
skin lesions present. No tache could be elicited. Kemig's sign was
absent. Her neck was symmetrical, thick in lower part due to slightly
enlarged thryoid. No thrill nor murmur over gland. Lungs were
normal. Heart was not enlarged, both sounds at apex and those at
base being clear and strong. The abdomen was on the level of the
ribs. Abdominal muscles were slightly rigid. Spleen was felt at edge
of ribs. No spinal tenderness existed.

With the history of ear involvement Doctor Canfield decided to dp
a paracentesis on the right tympanum. Bloody serum discharged, but
no pus was seen. Cultures were made of this, which developed diplo-
cocci.

Ice caps were applied to head and spine.

The following day found her much the same. Early in the morn-
ing, twitching of the extremities was noticed for a short while. Par-
tial consciousness returned at times. She was resting quietly towards

892 ORIGINAL ARTICLES.

noon, but took no nourishment Her bowels and urine were voided
involuntary, nor were enemata of any kind retained.

The ear was clean and very little serum discharged. At 1 130 p. m.
she had a profuse nosebleed requiring plugging of nares. There was
also a dark brownish-red vaginal discharge. Towards evening the
right sclera became markedly injected. Her eyes were partly open
most of the time and the pupils were becoming gradually more dilated.
The eye grounds were examined at this time by Doctor Slocum, who
found the vessels tortuous and congested with some edema in the right
fundus.

The patient's pulse and respiration gradually rose all day while the
temperature remained persistently high. Her muscles were becoming
more flaccid. Doctor Canfield performed a lumbar puncture at this
time recovering forty cubic centimeters of slighdy turbid fluid which
ran out under pressure. In the small sediment numerous intra- and
extracellular organisms were found. They were diplocococci of vary-
ing size and shape with a distinct capsule. There were no lanceolate
forms. Cultures made on blood serum showed watery looking colonies
which on staining proved to be diplococci. Soon after the first lumbar
puncture I made a blood culture of five cubic centimeters of blood in
seventy-five cubic centimeters of bouillon and incubated thirty-five
hours. The media became turbid. Stains of the growth showed a
diplococcus of equal length and breadth. A rabbit inoculated with a
few drops of the culture medium died in forty-eight hours, a typical
pneumococcus being recovered from all the organs and blood.

Following the drainage of the spinal canal, the patient was more

comfortable. The rigidity was less marked and she became somewhat

conscious on the following morning. Her blood pressure at this time

was 130 maximum systolic. Her temperature was little lower. The

pulse, however, was steadily increasing and became of less force and

volume.

j At 9 p. M. on the 23d she laid in passive dorsal position, eyes half

closed, mouth open with slight rigidity of back and leg muscles. Mucus

I was collecting in her throat and the breathing was decidedly labored, a

prolonged groan accompanying each expiration. Her extremeties

were warn and of good color. On auscultation of thorax, the heart

I sounds which were distinct and rapid were obscured by mucous rales

j heard all over the chest. There were no skin lesions and no tache cere-

I brale. The paralysis of all muscles was becoming marked. The pupils

dilated to light, while the comeae were steamy. Lumbar puncture

brought away thirty-two cubic centimeters of very slightly cloudy fluid

at this time. The symptoms were not relieved.

The temperature was gradually falling while pulse was growing
steadily weaker and more rapid along with the respiration, whidi two
hours before death reached forty-four per minute.

Death came about 4 a. m. about four days after the first marked
symptom complained of.

ACUTE MENINGITIS OF NASAL ORIGIN. 3d3

An autopsy was obtained and the brain and cord were examined
by Doctor Albert M. Barrett, to whom I am indebted for the following
notes:

EXAMINATION OF THE HEAD.

Eyes, — The pupils were four millimeters in diameter. The scalp
was not notable. The diploe laterally and posteriorly were slightly
congested.

Brain, — The dura mater was rather tense. Its inner surface was
smooth. The longitudinal and lateral sinuses were filled with a red and
yellow postmortem clot.

The cerebrospinal fluid was turbid and considerably increased in
quantity.

The convolutions were flatt^ied and closely approximated to each
other.

The pia mater over the entire convexity was clouded, its larger ves-
sels were deeply engorged with blood and the smaller vessels over the
surfaces of the convolutions were injected. Along the larger vessels
there were long yellowish streaks and in places, especially over the
frontal lobes, there were fibrinopurulent deposits. The pia mater over
the base in the region cisterna was thickened and covered with exudate
which obscured the nerve roots and the circle of Willis. The pia beneath
the pons and medulla was moderately clouded. Over the cerebel-
lum, especially in the region of the vermis, the pia showed considerable
exudate.

On cutting into the brain, the cortex showed a pinkish hue and
prominent vessel markings.

The subdural space of the spinal canal contained an increased
quantity of turbid fluid. The vessels of the pia mater were intensely
injected and the pia was infiltrated with exudate. In scattered patches
there occurred small deposits of yellow fibrinopurulent material.

Sinuses. — The ethmoidal sinuses contained considerable thick
yellow puriform material. The right tympanum was perforated
and the cavity of the middle ear contained turbid reddish fluid.

Microscopically, the exudate was more abundant in some place^
than in others. The larger amounts usually lay about the vessels, espe-
cially over the sulci. In some places, as above the summit of the convo-
lutions, the only changes noticed were a slight swelling of the fibers of
the pia and an occasional large mononuclear cell with the nucleus deeply
stained and of irregukir outline. All degrees of transition were pres-
ent between these cells and forms which were undoubtedly epithelioid
cells with pale irregular nuclei and often containing inclusions of red
blood cells or small deeply stained particles. Around the vessels there
were numerous polynuclear leucocytes. Fibrin threads were abundant,
especially near the vessels and where the exudate was thickest there
were many shadow forms of disint^^ded leucocytes and epithelioid
cells. There were only a few red Stood cells present in the exudate.

304 ORIGINAL ARTICLES.

Small, deeply stained bodies resembling cocci were irregularly dis-
tributed, in some places quite numerous and in others a few or none
at all.

The glia cells of the subpial layer of the cortex were generally swol-
len and showed well developed processes. Even in the deeper layers,
among the nerve cells, the glia nuclei showed progressive changes.

The nerve cells of the cortex presented a variety of pathological
forms. Some were swollen and had no Nissl granules, but the greater
number were in various reactive conditions, which did not conform to
any special type of alteration.

In sections from the spinal cord, the pia mater showed an abundant
exudate, resembling that occurring over the brain. Throughout the
entire length of the cord there were scattered small recent hemorrhages
among the fibres in the peripheral part of the cord. This must have
been quite recent as there were no reactive changes. In the fixed tissues
there was a slight distortion and swelling.

PATHOLOGICAL DIAGNOSIS.
Acute fibrinopurulent leptomeningitis.

Acute reactive changes in the nerve cells and neuroglia of the cortex.
Multiple hemorrhages into the spinal cord.
Purulent inflammation of nasopharynx, and of right middle ear.

« ♦ «

Smears of the pus from the meninges of both the brain and cord
gave numerous diplococci both in and out of the polynuclear cells. Each
organism was small and spherical in shape. By Welch's method a dis-
tinct capsule could be demonstrated. The pus from the sphenoid sinus
and from the right middle ear showed like organisms in considerable
numbers.

The examination of the remainder of the body was conducted by
Doctor Elmore E. Butterfield. Other than terminal and postmortem
changes nothing pathological was found.

That this was a malignant case from the outstart was certain. The
rapidity with which the symptoms developed and the character of the
infecting agent left no hope for a favorable outcome. The name apo-
plectic given to these rapidly fatal types of meningitis is truly a deserv-
ing one. Perfectly well in the morning, stricken at night with an unen-
durable headache which grows more intense each minute, tremors and
clonic spasms developing soon to be replaced by tonic contractions, coma
coming on before twenty-four hours are past, paralysis gradually devel-
oping as the centers become exhausted, — this is the picture that prevails
in the majority of the cases of pneumococcic origin.

Knowing the source of the case the possible dangers of contagion
were ominous in the beginning. Especially the fact that the districts
in which the patient had taught suffered most severely from the
scourge, added to the likelihood of this being a meningococcus infection
(Billings). Hence every precaution indicated in such a case was

ACUTE MENINGITIS OF NASAL ORIGIN. 39&

employed. The result of lumbar puncture, however, revealing the pneu-
mococcus determined the danger of further spread.

Before autopsy the ear seemed a probable road of infection. Post-
morterm examination left no shadow of doubt but that the nose was the
avenue by which the virulent pneumococcus reached the meninges. The
ear was probably involved secondary to the brain. Whether or not
chronic sinusitis as revealed was the immediate cause is open to argu-
ment. Suffice to say it made the tract more viable for invasion.

One factor that we must take into consideration in this case is the
general infection that existed as shown by recovering the pneumococcus
in pure culture from the blood. What part did it play in moulding the
course of the disease? Despite the extensive meningeal involvement I
am almost inclined to think that the intense intoxication resulting from
the pneumococcaemia had much to do in bringing about the rapidly fatal
end.

BIBLIOGRAPHY.

"Reports of American Public Health Association," September, 1905.

Elsner, H. L. : Medical News, April 8, 1905. "Symptoms and Diagnosis of
Cerebrospinal Meningitis."

Councilman: Journal of American Medical Association, April i, 1905.
"Acute Meningitis."

WiLLsoN, R. N. : Medical News, October 14, 1905. "Four Cases of Cerebro-
spinal meningitis."

CuPLER, R. C. : Medical Record, November 18, 1905. "Primary Cryptogenic
Pneumococcus Cerebrospinal Meningitis."

Wilson, J. C. : Jorunal of American Medical Association, April 28, 1905.

Barras : Lancet, August 27, 1904. "Meningial Infection by the' Pneumococ-
cus."

Speer, G. G. : Medical Record, April 15, 1905. "Cerebrospinal Meningitis-
Epidemic and Sporadic."

Gottseen, a.: Deutsche Medicinische Wochenschrift, Band XXXI, Num-
ber XXIII. "Die Geschichtc von Cerebrospinal Meningitis."

Hastings: Medical News, June 17, 1905. "Cerebrospinal Meningitis."

KoPLiK, H. : Medical News, June, 1904. "Clinical Features of Cerebrospinal
Meningitis."

Chapin: Medical News, June, 1904. "Notes of Epidemic Cerebrospinal
Meningitis."

Soerensen: Yahrbuch fiir Kinderheilkunde (Berlin). "Fieber und Krank-
heitsbild der Epidemischen Cerebrospinal Meningitis."

Abbott, A. C. : University of Pennsylvania Medical Bulletin, 1905. Occur-
rence of Epidemic Meningitis in Philadelphia."

Goodwin, M. E., and von Sholly, A. I.: Journal of Infectious Diseases^
February, 1906. Frequency of the Meningococcus in the Nasal Cavity of Men-
ingitis Patients and thqse in Direct Contact."

Bolduan, C, and Goodwin, M. E.: Medical Neu^s, December 23, 1905.
"Ginical and Bacteriological Study of Cerebrospinal Meningitis and the Prob-
able Source of Contagion."

Hare, H. A.: New York Medical Journal, February 10, 1906. "Case of
Cerebrospinal Meningitis Indicating that it may be of Contagious Nature."

Weichselbaum, a. : Wiener Klinische Wochenschrift, Band XVIII, Number
XXXI. "Zur Frage der Aetiologie und Pathogenese der Epidemischen Geneck-
starre."

BiLUNGS, J. S., Jr. : Journal of the American Medical Association, June 2,.
1906. 'Cerebrospinal Meningitis in New York City during 1904 and 1905."

306 ORIGINAL ARTICLES.

LESSONS IN LONGEVITY.

JOHN S. CAULKINS, M. D.
FOURTH PAPER.

These studies* in longevity so far have considered the matter
mainly from the physical or objective point of view, but not to leave the
question half discussed it is equally necessary to look at the subjective
side. We will now study the effect of the mental and moral factors
that lead to the prolongation of active and useful life. Assuming that
the human unit has received as fair treatment as the present imperfect
conditions allow, he finds himself at puberty confronted with a change.
He is no longer to have things done for him ; he must do for himself,
and for others, too. He becomes a worker and must do his share of the
things the world needs done, thus repaying the debt he owes fpr what
was done for him in infancy and youth. He must put into practice that
which he has been taught and if possible improve on the teachings. As
responsibilities increase, so do the influences which tend to produce con-
ditions of mind unfavorable to longevity. These unfavorable conditions
are the product of all violent passions : they are all life-shorteners and
prominent among them is —

Anger, especially when it degenerates into unreasoning rage, leading
to inveterate hatred and thoughts of revenge. Such anger is a consumer
of energy — ^a constant flame which burns the store of stamen vita pro-
vided for the staff of declining age. Whoever wishes to reach a hale old
age must learn to avoid sudden bursts of anger, and the earlier the les-
son is learned the better. '

Greed is equally, perhaps more, hurtful. The love of money has
ieen designated the root of all evil, but conceding that there are other
causes of evil it is plainly to be seen that the inwdinate love of money
for its own sake, or for the sake of the power it gives its possessor, leads
to covetousness, dishonesty, and crime. Of course, in our imperfect
state of human society, money is necessary as a medium of exchange
and a common denominator of values, but too much of it is bad for the
possessor and bad for the community, since in order that one may have
too much it is necessary that others must be exploited and robbed of their
rightful share. The tramp is the corollary of the millionaire.

Fear is another mental condition inimical to long life, while its oppo-
.site, courage, is in the same degree friendly. Fear weakens and
paralyzes the efforts of mind and body. Courage invigorates and
strengthens. Courage does not consist in running heedlessly into dan-
ger, prudence being always commendable, but it is only the courageous
who can act prudently ; one frightened out of his wits cannot. To live
long requires a large stock of courage. Let everyone, then, retain his
courage and banish fear by keeping in mind and emulating the example

♦Thp writer of these papers did not have assurance to seat himself in the
ieacher's chair by calling them "Lessons," they being indebted* for it to the
friendly offices of the editor.

LESSONS IN LONGEVITY. 39T

of the courageous. Where a lack of courage is accompanied by a too
lively imagination and ill regulated nerves, results are especially deplor-
able, running into hypochondria and monomania. In illustration of this
we are indebted, for the true story below, to Alexander Monro
(Primus*), Professor of Anatomy at the University of Edinburgh in
the first half of the eighteenth century. While finishing hi$ studies
under the celebrated Boerhaave, of Leyden — the greatest medical light
of the eighteenth century — ^he had, he says, a fellow-student of the above
unfortunate type of mind, who was afflicted with fear to the degree that
when Boerhaave lectured on any particular disease, he became firmly
convinced that he himself had that very disease. The result was that in
a short time he became really ill and was obliged to relinquish the study
of medicine.

Envy and jealousy of the good fortune of others is the vice of little
minds and a great handicap in the race for long life, while contentment'
and good will to all are in the same d^jee assistants. Let us cultivate
peace and good will to others and if inevitable misfortune overtakes us,
not waste our strength in weak repinings and useless struggles, remem-
bering that though our disappointment is g^eat, we are still much better
situated than many others who probably have feelings as acute as our
own. This does not mean that we must tamely submit to injustice,
resistance to that being a duty owed not only to oneself but to others.
The sense of having discharged to the best of our ability a disagreeable
duty ; of having battled for the right, and done our best to resist the
wrong, tends to make us independent of misfortune and trouble, and
gives us the right to be proud of ourselves. Such feelings make strongly
for longevity, being a mental tonic which the mind reflects onto the
physical organization. Whoever is desirous of living to be very old
mtist beware of that mental canker, envy. He must school himself to
be what the shepherd in "As You Like It" says of himself, "envious of
no man's good— Content with his own harm."

Idleness is another antagonist to longevity. Any mechanism, the
human body not excepted, if kept well lubricated and clean wili last
longer running than when lying idle and neglected. Work is good for
us, but to have the best results we ought to love work and not over-
work. Idleness means rust to mind and body. "It is better," says the
proverb, "to wear out than to rust out." This proverb has reference to
wearing out prematurely by overwork, for the certainty is evident, that
we will all be worn out when our inherited stock of vital force is spent.
A certain amount of manual labor, guaged according to strength and
age, is good for every adult well person, rich or poor, and this should
be complemented by some intellectual labor guaged in the same way,

♦The University of Edinburgh had three professors of anatomy by the name
Alexander Monro, their professorial careers extending from 1820 to 1859—139
years — father, son and grandson succeeding one another without break or inter-
val. All three having &en eminent in the pursuit of their chosen science — hav-
ing written many books — they are cognosed from each other by the Latin numeral
adjectives — Primus, Secundus, and Tertius.

3W ORIGINAL ARTICLES.

but the plan is not very practicable in our present imperfect state of
society, since the two idle classes — ^the blots on our civilization, — the
idle rich and the idle poor will not do work of any kind. When the
world is reorganized on a strictly scientific basis this evil will be cor-
rected and every one will do as much manual labor as is good for him,
leaving plenty of time for development of the intellect and recreation
from toil.

WoRRiMENT is mentioned last, but it is not the least among the life-
:shorteners. Fretfulness and peevishness are debasing habits — ^sadly det-
rimental ta equanimity and serenity of mind necessary to growing old
slowly. They frazzle out by their friction the statnen vita until it parts
prematurely. Whoever feels himself attacked by them must sturdily
resist or be crushed by the load that time will soon throw on his weak-
ening shoulders.

We are taught by this review of the mental conditions that wear us
■out and destroy our opportunity for a longer existence, that we must, in
the words of a certain ritual, learn to subdue our passions. The earlier
we learn the lesson the better our chance for success will be.

Little need be said on the moral side of the question, the laws of
morality having varied little in any age and country since history was
first written. Recent discoveries of records reaching several thousand
years before the Christian era to the time of Hamarubi, the lawgiver
of ancient Chaldea, show that he made laws against the same vices and
crimes that our legislators do. It only remains to say in this connection
that we must be good citizens and obey the laws of our country, remem-
bering that there are things that statute laws cannot punish that are
contrary to the unwritten laws of honor and honesty. Christ sums thi^
all up in His Golden Rule, **Do unto others as you would have them
do unto you." Whoever makes this his undeviating rule of action need
have no fear that there is a skeleton in the closet to frighten him from
living peacefully as long as he can.

DEDUCTION FROM THE ABOVE. AND PRACTICAL RULES TO
KEEP ONE YOUNG.

Since we are no older than we feel ourselves to be, and those who
can eat, digest and sleep well, are really well, it follows that the answer
to the question how to delay the arrival of decrepit old age, lies in dis-
covering how and what it is best to eat and what will best promote sound
healthful sleep. We are made of what we eat, and hence we must sup-
ply good material. We cannot live without sleep and therefore it
behooves us to study its laws and comply with its requirements. In the
schedule of rules below every one is based on its relation to diet or to
sleep.

DIET.

( 1 ) Never eat unless you are hungry.

(2) Do not eat too much — stop before full repletion.

LESSONS IN LONGEVITY. 399

(3) Never drink while eating, but take a satisfactory drink of
pure cold water afterward.

(4) Bread is the staff of life. Let it form the main part of every
meal. It includes whatever is made "from the cereal grains — ^the baked
loaf, crackers, griddle cakes, mushes, et cetera.

(5) Wheat makes the best bread for our climate — Indian corn is
a good second, oatmeal a third, then follow rice, buckwheat and rye.

(6) Do not forget to salt the bread well. Employ about twice as
much salt as most cooks do. «

(7) Besides bread, eat garden vegetables in season; fruits; nuts;
eggs; the products of the dairy — ^milk, butter, and cheese — ^the best
cheese being the cottage or Dutch variety made of sour milk with a very
gentle heat, leaving out the black pepper.

(8) Elect a dietary comprising the following:

For breakfast. — Mush of some kind, mostly of whole wheat meal ;
toasted bread with butter ; perhaps custard eaten cold, or stewed prunes.

For dinner, — Bean soup ; vegetables in season ; a pudding of bread
made with eggs, milk, and sugar, eaten with cream; melon in season.

For supper, — Bread and milk; apples — baked or raw, and a little
cheese.

(9) Importance is attached to the plan of using the garden veg-
etables in the order of season. By so doing we get nearer to Nature's
heart and the simple life ; we collect from each of her perishable pro-
ducts, the good things she has just formed for us in their fresh and
most perfect condition. This remark applies to many other kinds of
food — eggs and butter especially, — as well as to vegetables. Careful
observation of this caution helps us to live on the best and purest food
all the time. We cannot be too careful about the quality of our food.
Poor nutrition means imperfect cell formation and that means short life.

HINTS 6n the use OF A SUCCESSION OF VEGETABLES.

As soon as the frost is out of the ground we have oyster plant,
parsnips and horseradish, of which the first is the most important, par-
snips being rather indigestible, and horseradish valuable mainly for its
medicinal qualities as a prophylactic against scorbutic diseases ; but
oyster plant is a most important article of diet. It is a root full of rich,
nutritious milk which cannot be too highly recommended. Then follows
the pieplant which fills a wide sphere of usefulness as the earliest acid
5auce. About the middle of May comes, in the opinion of the writer,
the most useful of all garden vegetables, asparagus, and it is in season
until July. This high estimate of its value rests on the fact that for fifty
years, he, for six weeks each year, made his noon meal almost wholly of
bread and asparagus. A still older friend of his has done the same for a
longer period. We can be quoted for hale old folks. We of course
know "that one swallow does not make a summer," but we cannot help
thinking that the immense amount of asparagus we have eaten has had
something to do with our prolonged heartiness. For July our staples

400 ORIGINAL ARTICLES.

will be peas, beans, and onions ; for August tomatoes and green cx)m.
The latter cooked Indian fashion with beans makes a substantial, deli-
cious life-giving food. Sweet com planted in succession will last until
frost comes, and then follow the Brassica tribe and squashes. Through
the winter the potato is preeminently the staple vegetable food, although
with care many of the others can be preserved without deterioration.

All sanitary rules are formulated with reference to diet or ^leep.
Having dilated on the first prerequisite we now consider the second —

SLEEP.

(i) A large well ventilated sleeping room with a southern expos-
ure is an important adjunct to health — ^a chamber being preferable to
the ground floor.

(2) Allow of all the sunshine possible, keeping the windows open
at night as long as the weather permits.

(3) Cleanliness of room, clothes and person is essential, cleanliness
being next to godliness.

(4) Never sleep in the same clothing worn during the day.

(5) Avoid having fire or lamp burning all night in your bedroom.

(6) Have the head of the bed a little higher than the foot, and
pointing north.

(7) Retire as soon as you feel sleepy.

(8) Never retire with cold feet. If subject to such, dip them into
cold water and rub until warm.

(9) Sleep all you can and as much as possible before midnight.

(10) If troubled with wakefulness, instead of taking drugs try
massage as a remedy — using a wire brush for the head. Time spent in
massage of the surface of the body is not time lost — it is time lent.

These rules comprise about all we now know regarding longevity,
and if carefully observed, cannot fail, unavoidable accident or misfor-
tune excepted, to keep us alive and stirring long after w^ have passed
the present limit of human life, and when the inevitable hour arrives,
the mechanism that keeps us alive will be more apt to stop suddenly and
let us drop off painlessly into the sleep from which we never awaken*

[COlfCLVDBD.]

METATARSALGIA.*

WILLIAM E. BLODGETT, M.D.

The object of this paper is to offer a few remarks about a some-
what rare but often striking orthopedic lesion and to illustrate the
treatment of it. The condition referred to is anterior metatarsalgia or
Morton's toe. The rarity of the condition is shown by a series of one
thousand hospital cases of foot-trouble due to faulty weight-bearing,
collected by the writer.f In this series, only sixty-eight were metatar-
salgia, and only ten had the sudden, severe attacks of pain. In the last
six months, however, three patients with the characteristic sharp
attacks have come under the writer's care, as well as three patients

♦Read before the Ann Arbor Medical Club. September 12, 1906.
^Journal of the American Medical Association, August 20, 1904.

METATARSALGIA, 401

with chronic metatarsalgia. These six cases form the basis of the
demonstration.

The cardinal feature of metatarsalgia is pain at the base of the
small toes, especially the fourth toe. The pain is provoked and aggra-
vated by use of the foot. There are two types of this pain: first,
chronic pain and soreness; and, second, intermittent, sharp attacks of
pain. The chronic type is commonly accompanied by a noticeable flat-
tening of the transverse arch of the foot made of the heads of the
metatarsals, and by a callus beneath the flattened transverse arch. The
acute type often occurs in an apparently normal foot. The acute type
is striking because of the suddenly produced, almost complete disability.
The patient, usually a woman, is forced to sit down on the curb, or
wherever, and remove the shoe. One patient, particularly careful
about her appearance, would often come home from the evening's
entertainment stocking-foot, nauseated by the pain. The onset of the
pain is often announced by a feeling of something in the front of the
foot slipping; one lady said it felt like the "slipping of a cog." In the
same way, some manipulation of the front of the foot will often stop
the severe pain.

The cause of the pain in the chronic type of metatarsalgia, as in the
ordinary pronated foot, is general abnormal tension and pressure. In
the acute type, however, the pain is due to a displacement of the heads
of the metatarsals in relation to each other, such that one of the digital
branches of the external plantar nerve is squeezed between two of the
metatarsal heads. This nerve pressure usually occurs on one side or
other of the head of the fourth metatarsal, so that the pain is referred to
the fourth toe. A structural change in the heads of the metatarsals,
as after a fracture, is occasionally accountable for the nerve pressure.

The principle of treatment is to prevent the cause of the pain. In
the chronic type, the anterior arch requires support either by natural or
artificial means. The measures to favor natural support are a broad
right-shaped shoe, correct toes-to-the-front gait, stimulative applica-
tions to the feet as alternately hot and cold bathing, and exercises for
the feet to strengthen flexion of the toes. An exercise that is of use is
for the patient with the feet bare to pick up with his toes two or three
dozen one-half inch marbles and first with one foot and then with
other to replace jthem in the box. The general health may need atten-
tion. Artificial support is supplied by adhesive plaster strapping and
more permanently by a sole plate, both of which are to be demonstrated.

In treatment of the acute t)rpe, the measures for favoring natural
support are the same as in the chronic type. The acute pain can
usually be immediately stopped and return of it temporarily prevented
by manually pushing up the middle metatarsal heads and drawing
down the sides of the foot ; this position is retained by a felt pad about
one-quarter inch thick and one inch by one-half inch, placed under the
middle metatarsals and by adhesive strapping holding the pad in place

402 ORIGINAL ABSTRACTS.

and the sides of the foot drawn down around it, as is to be demon-
strated. Permanent artificial support is supplied by a plate similar to
that used for the chronic type but more extreme. Operative removal of
the head of the fourth metatarsal is rarely necessary.

Detroit t Michigmu.

ORIGINAL ABSTRACTS.

SURGERY.

FRANK BANGHART WALKER, Ph. B.. M. D.

nOPUSOK OP SUKGnr AMD OrBHATiyV SUKGBKT in the DBTKOIT PORGKADUATB school of MBOiaiCB;
ADJUNCT PROPHSOR OP OPBRATIVB SUMGBKT IN TMB DBTROIT COIXBOB OP MBOICINB.

AND

CYRENUS GARRITT DARLING. M. D.

CUNICAL PB0PBS60B OP SUBGBST IN TMB UNIYBBSITT OP MICHIGAN.

MORTALITY AFTER OPERATIONS UPON THE GALI^
BLADDER AND BILE PASSAGES.

In a summary of fifteen hundred operations upon the gall-bladder
and bile passages, William J. Mayo, in the Annals of Surgery, Volume
XLIV, Number II, indicates the trend of surgical practice in these cases
and compares the development of surgery in this field with that of
appendicitis. He states that there were 845 cholecystostomies with a
mortality of 2.13 per cent. There were 319 cholecystectomies with a
mortality of 3,13 per cent. There were 207 operations upon the bile
passages with twenty-seven deaths, about 13 per cent, arranged in four
groups: Group I, 105 cases with three deaths, 2.9 per cent, consisting
of those patients in whom gall-stones were present in the common duct
but without immediately active symptoms. Group II, 61 cases with ten
deaths, 16 per cent. In this series there was active infection not only in
the common duct but also involving the ducts of the liver. Stones were
usually present. Group III, 29 cases and ten deaths; 34 per cent. In
these there was complete obstruction of the common duct. In group
I\^ which concerned malignant disease, there were 12 cases with four
deaths ; 33^^ per cent mortality. The total number of deaths following
the 1,500 operations was sixty-six, an average mortality of 443 per
cent.

The author states that the mortality in the first i,odb cases was 5 per
cent ; in the last 500 3.2 per cent. The death rate after cholecystostomy
in the last five hundred cases was 1.47 per cent. In the last 500 cases he
also lowered the death rate after cholecystectomy to 1.62 per cent. This
view illustrates the merit of experience and selection of cases.

From the standpoint of mortality cholecystostomy is the safest opera-
tion for the average case, and yet in the author's hands removal of the
gall-bladder has been followed by nearly as good results. He reasons
that as the best surgical practice removes the appendix while yet the
disease is confined within it, so removal of the disease while still in the
gall-bladder will show a mortality of less than one per cent. "With tKe

OVARIAN CYSTS. 403

passage of the stone into the common duct we no longer have a localized
disease but one fraught with grave dangers frcmi liver infection and
cholemia, and in this condition nearly one in seven of our cases came to
operation, while one in twenty-five developed malignant disease of the
gall-bladder, or bile tract, and in most of these cases gall-stones were
present. In other words, one patient in six had allowed the favorable
time to go by, although the very large majority had ample warning in
the early and safe stage for operation." f. b. w.

OBSERVATIONS UPON THE ANATOMY OF THE DUO-
DENUM.

Again, in the Afnerican Journal of the Medical Sciences, A. J,
Ochsner calls attention to the finding of a marked thickening of the cir-
cular muscular fibres of the duodenym at a point below the entrance
of the common duct. In some cases he has found a narrow circular band
forming a distinct sphincter ; in other instances the thickening was dif-
fused, making a broad circular band ; and in a few instances the thicken-
ing was in two different bands, with an intervening portion in which the
circular muscular fibres were of the same thickness as the remaining
portion of the duodenum. In most specimens the sphincter was located
from three to ten cubic centimeters below the point of entrance of the
common duct, while in a few instances a portion of the sphincter
included a point of entrance of the common duct, the remaining portion
however, being always located below this point.

It seemed to the author as though this arrangement of circular mus-
cular fibres served the purpose of a sphincter to facilitate the process of
mixing the bile and the pancreatic juice in the duodenum, f. b. w.

GYNECOLOGY.

REUBEN PETERSON, A. B., M. D.
raorassoR of CTifscoLOcnr and obststrics in thb univkssitt ov mxcbigam.

AND
CHRISTOPHER GREGG PARNALL, A. B., M. D.

FORMSRLT FIRST ASSISTANT IN GTNBCOLOGT AND OBSTSTRICS IN TKB VNIVXRSITT OF MICHIGAN.

OVARIAN CYSTS SITUATED ABOVE THE SUPERIOR
PELVIC STRAIT, COMPLICATED BY PREGNANCY.
Patton (Surgery, Gynecology, and Obstetrics, Volume III, Num-
l)er III) reports three cases occurring in the University of Michigan
Gynecologic Clinic, and reviews three hundred twenty-one cases col-
lected from the literature. The writer's study was confined to a con-
sideration of cystic tumors lying above the true pelvis and from
statistics drawn from these cases he has formulated the indications for
appropriate treatment. The cases are tabulated according to the
treatment employed, that is: (i) Not interfered with; (2) Tapped;
^3) Laparotomy; (4) The child delivered by artificial means.

404 ORIGINAL ABSTRACTS.

(i) Treatment Expectant, Ninety-five Cases, — During pregnancy
and labor the dangers from the expectant plan of treatment are not so
great as in the pucrperium. Twisting of the pedicle of the cyst is very
apt to occur when the ligaments are lax after labor. Probably due to
the torsion of the pedicle is the large number of cases of suppuration,
hemorrhage, rupture, and peritonitis. The maternal deaths in this
series of cases were twenty-five, or 26.3 per cent. Interrupted preg-
nancies, eighteen — 9 per cent. Laparotomies after labor, forty-nine, or
51.5 per cent. Deaths, four, or 8.1 per cent. No operation, forty-six,
or 48.5 per cent. Deaths, twenty-one, or 45,6 per cent.

(2) Laparotomy, One Hundred Twenty-four Cases. — In this series
operation was done from the second month to full term. The maternal
death-rate was only 4.3 per cent. Interruption of pregnancy occurred
in nineteen per cent of the cases, practically the same as under the
expectant method. Twisted pedicle was found forty-six times, or
25 per cent.

(3) 7"a/>/>m^, Thirty-one Cases, — There were twelve maternal
deaths. Rupture of the cyst occurred six times before labor. Only one
case of twisted pedicle was encountered. Pregnancy was interrupted
in 54.8 per cent of these cases.

(4) Other Methods, — Cesarean section, accouchment force, deliv-
ery by forceps, version, and embryotomy were employed in eleven
cases. Five cases were operated during the puerperium with success-
ful results. In the remaining six cases, there were four deaths.

Briefly, the writer concludes that ovarian cyst is not an uncommon
complication of pregnancy, and when occurring it is a dangerous condi-
tion. Complications in ovarian cysts are more frequent during preg-
nancy and the puerperium than in the nonpregnant state. Tapping
gives only temporary relief and is a dangerous procedure. If the
expectant plan is followed during pregnancy and labor, the cyst should
be removed as early as possible in the puerpjerium. The treatment
giving the most favorable results is laparotomy and removal of the
tumor before labor, as soon as the diagnosis is made. c. g. p.

Jackttm, Michigan. ^^^^^^^^^^^^^^^^^^^

OBSTETRICS.

WILLIAM HORACE MORLE Y, Ph. B., M. D.

DBMOHSTRATOK OP OMTSTAICS AMD GTHBCbLOGT IM THS UMIVBKSrrT OV MICRI6AM.

AND

ROLLAND PARMETER, B. S., M. D.

A CASE OF INTRALIGAMENTARY FULI^TERM EXTRA-
UTERINE PREGNANCY.

RoDiGER (ZentraJblatt fiir Gynakologie, Number XXXI, August 4,
1906) describes the following case: A farmer's wife, thirty-six years of
age, confined in 1897 and 1899, with one abortion in 1900 as a result of
typhoid, became pregnant toward the end of November, 1964. Patient.

EXTRAUTERINE PREGNANCY. 405

gave no history of difficulty in lower abdomen. Fetal movements were
felt, the beginning of April, 1905. She continued her customary
house and field work until the end of August, when she had labor-like
pains which continued a few days. Along with these labor-like pains she
passed bloody clots from the vagina. Toward the beginning of Sep-
tember fetal movements ceased. At the end of September, and
November she had vaginal bleeding similar to her regular periods. The
circumference of the abdomen remained unchanged during these
months.

Patient came under Rodiger's care early in December, 1905. His
examination revealed uterus empty, a cyst-like tumor pressing it to the
right and upward. The lowest portion of the tumor was on a level
with the cervix and the highest point reached four finger breadths
above the umbilicus, being quite immovable. In the left vaginal wall
a hard round body could be felt. This was taken to be the head of a
fetus. From the breasts came milk in goodly quantity.

A diagnosis of extrauterine pregnancy was made upon the fore-
going findings :

An operation was performed December 11, 1905. A median
incision was elected. A tense and fluctuating tumor covered with
peritoneum presented, apparently arising from the pelvis: Toward the
left it was intimately adherent to the parietal peritoneum. The
adhesions on the posterior surface were very easily separated. The
culdesac of Douglas was entirely free. .The abdiCMninal wall was
sutured to the tumor, shutting off the abdominal cavity in such a man-
ner as to leave a segment of 10 x 5 centimeters of the tumor free.
The tumor was opened through this free space, and containedi one and
one-half liters of dark green fluid, and the lining wall was also colored
a dark green. The child was extracted by a foot' and weighed eight
pounds. Umbilical cord led to placenta adherent in bottom of cavity.
The placenta was left in the sac, its cavity being first cleansed out
and then packed with iodoform gauze.

The case went to recovery without a rise of temperature (so the
author says). Upon the twentieth day the placenta was easily removed,
without bleeding, and in three weeks more the abdomen ctosed by
granulation, no fistula remaining.

Patient was examined three months later when her usual health was
found fully restored, she being able to do her customary work. The
vaginal examination revealed scarcely a trace of thickening in the left
ligamentum lata. The uterus was free and in the middle line. In
neither adnexa nor culdesac could any pathological condition be deter-
mined.

The author, quoting Desguin, of Antwerp, says that the adhesions
of extrauterine pregnancy are mostly of a mechanical nature and after
their separation seem to entirely disappear, while adhesions due to
infectious causes last much longer and possibly never disappear.

406 ORIGINAL ABSTRACTS.

Schauta says the diagnosis of extrauterine intraligamentary preg-
nancy, with the abdomen open, is only positive when the "tumor"
extends well up and out of the pelvis with separation of the layers of the
ligamentum lata and the culdesac is entirely free.

The ccmiplete extraperitoneal position of the intraligamentary-
developed sac made the prc^;nosis in this form of ectopic pregnancy
comparatively favorable. The fetus could develop to a normal full-
term, and in this case quite likely, if it had come under observation and
in competent hands three months earlier, a living child would have
been the result.

Mobius called attention in 1903 to the comparative painlessness of a
developing intraligamentary extrauterine pregnancy in contradis-
tinction to that of an ectopic developing in the free abdominal cavity.

The operation in this case was comparatively simple. The extir-
pation of the fruit-sac was not done. The expulsion of the placenta was
safely left to nature. After removal of the afterbirth the two layers of
the ligamentum lata quickly united themselves. The most important act
in the whole operation would be absolute closing off of the abdominal
cavity before opening the membranes, thus preventing the entrance of
septic material from the fruit-sac into the peritoneal cavity. (The
reviewer feels justified in casting doubt upon the propriety of proce-
dure in this cctse. Would not an entire shelling out of the fruit-sac
from between the layers of the ligamentum lata — and this is comparer
tively easy, — removal of redundant tissue, suture of the parts and a
proper closure of the abdominal wall, thus avoiding future dangers of
hernia, been the better procedure?) Ref .

The case is of further interest inasmuch as the patient was a
farmer's wife, never having complained of difficulty in the lower abdo-
men. Any previous infection with gonorrhea could be almost with
certainty excluded, and there is no ground to assume the presence of an
acute or chronic condition in the region of the tube at time of impreg-
nation. The history and subsequent findings favors the view and sug-
gests that possibly the cause of ectopic pregnacy may be looked for
in the ovum itself. r. p.

PEDIATRICS.

ARTHUR DAVID HOLMES, C. M.. M. D.

COLD-AIR TREATMENT OF INFANTILE PNEUMONIA.
This paper is discussed in a vigorous manner by Doctor W. P.
Northrup, Professor of Pediatrics in Bellevue Hospital Medical Col-
lege {N€w York Medical Record, February 18, 1905). The method
is such a startling change from the orthodox treatment of past gener-
ations, and yet so in line with recently acquired knowledge in other
directions, that it is time for the profession of medicine to call a halt

TREATMENT OF HIP DISEASE. 407

and overhaul its stock opinions. If the child's temperature is 105®
Fahrenheit it is certainly illogical to make it higher by hot chest poul-
tices, heavy coverings, crib in a corner of the room, steam kettle boil-
ing, gas leaking into room, and every breath of fresh air carefully
excluded. Yet this is just the course instinctively followed by every
mother, who always associates pneumonia with cold and its cure with
heat. Northrup details two desperate cases treated upon the opposite
plan, and though he leaves but little doubt as to the perfect reasonable-
ness of it all, it is to be confessed that it will be difficult to make the
average mother carry out the treatment. A room temperature which
compels the attendants to wear overcoats and furs does seem harsh,
but if the results are explained there should be no complaint. Cyanosis
disappears, the blood reddens, restlessness diminishes, sleep comes on,
the heart is stronger, the respiration is less labored, indigestion is
improved — ^and all from the cold air which bathes the little sufferer's
face and enters its lungs. If such great good can be accomplished by
this simple means, surely an effort should be made to induce mothers
to carry out the method in all such cases.

ORTHOPEDICS.

IRA DEAN LOREE, M.D.

FIBST AaSISTANT IN SURGBRY Ilf THB UNXVBRSITT OV MICHIGAN.

THE CONSERVATIVE; TREATMENT OF HIP DISEASE.

S. J. HuNKLiN, M. D., of San Francisco, in the American Journal
of Orthopedic Surgery, July, 1906.

Without attempting a definite diagnosis, in many cases, he includes
under this heading those diseases which present the symptoms of lamed
function, limp, spasm and interference with the extremes of motion,
especially rotation. His paper deals principally with the treatment
of the condition which in his judgment is conservative, even in the class
that goes on to suppuration and abscess formation. He regards rest as
the essential principle, and, as the work performed by a joint is of two
kinds, namely, motion and w€ight-carr)ring or friction and pressure, it is
best obtained by immobilization and traction. By these methods abso-
lute rest is obtained during the acute stage of the disease, after which
time work within the limits of pain and spasm is more desirable. Out-
door life is strongly advised and these patients should never be con-
fined to the house when the treatment can be applied with them up.

When complicated by abscess no change in treatment is necessary
more than aspiration of its contents. If the latter condition exists and
goes on to ulceration, confinement to bed may be advisable for reasons
of cleanliness, the wound being dressed with sterile gauze and any med-
dling with it prohibited. This plan of treatment is preferable to opera-

408 ORIGINAL ABSTRACTC.

tion even in those joints which show the whole epiphysis to be disor-
ganized, when no joint line can be distinguished and clinically the head
of the femur is on the dorsum of the ilium. When the latter condition
prevails he relocates the head of the bone at once under an anesthetic.

OTOLOGY.

R. BISHOP CANFIELD. A. B., M. D,
psovBsaoR am otolasyngologt in tmb uniybssitt ov micmigaic.

AND

MARSHALL LAWRENCE CUSHMAN, M. D.

MMOIWTKATOK OP OTOLAKYIVGOLOGT IK THE VMimtSmr OV MICMIGAM.

WHAT CASES OF CHRONIC PURULENT OTITIS REQUIRE
THE RADICAL OPERATION.

Knapp, of New York City, in Volume XXXV, Number II, of the
Archives of Otology, considers that the present tendency is toward
greater conservatism in the treatment of chronic purulent otitis media
and notes Ballance as the only one who still insists that all these cases
be treated by the radical operation.

Leaving out cases complicated by intracranial extensions, stenosis of
the canal, or acute mastoiditis, the author arranges the remaining cases,
according to the classification of the Berlin Ear Clinic, as dangerous and
as not dangerous, the former series comprising those in which the bone
is affected, especially in the attic and antrum, and the latter in which the
inflammation is localized to the mucous membrane of the tympanum.

Bone involvement may be recognized by the characteristics of the
discharge, its odor, and by the otoscopic picture which shows a total
defect or a posterior and superior marginal perforation of the drum.
The presence of cholesteatoma is important and if there is retention it is
an urgent indication for operation. Cases showing simply chronic osse-
ous involvement may often be benefited by conservative treatment but
this procedure failing, operation should be considered. Headache, nau-
sea, and vertigo are important symptoms and usually indicate operative
measures though the first may be but a manifestation of hysteria. In
the second group of cases one finds anterior or central perforaticms and
usually involvement of the tube. Even in some of the dangerous cases
minor operations will suffice and the patient is safe while under occa-
sional observation. It is also important to ccmsider the hearing in the
other ear for one cannot guarantee but that the hearing will be dimin-
ished after operation. His conclusions are as follo>ys :

The operation is not indicated when the tympanum and especially its
mucous lining are involved, because intracranial complications are not
likely to ensue and the operation usually accomplishes nothing.

The operation is urgent when the symptoms of headache, nausea,
and vertigo are associated with, and in relation to, chronic purulent

PALLIATIVES FOR HAY FFVER. 409

Otitis ; when the bone is found affected or cholesteatoma is present, and
these S3rmptoms are not promptly relieved by a minor operation.

The operation is indicated when signs of bone involvement continue
after conservative treatment has been followed for a certain length of
time and the odor in the discharge persists. The operation is not neces-
sarily urgent in these cases, as good drainage is present. The question
of operation then depends on the patient's wishes and the condition of
hearing in the other ear. m. l. c.

LARYNGOLOGY.

WILLIS SIDNEY ANDERSON, M. D.

CLINICAL PROPBSSOR OP LARYNGOLOGY IN THE DBTROIT COLLBGB OF HBDICINB.

PALLIATIVES FOR HAY FEVER.

Solomon Solis-Cohen {Jama, July 28, 1906) first considers the
suprarenal preparations. He advises the use of the active principle of
the suprarenal gland made into tablets, with a little sugar of milk, in
doses of one-fortieth to one-tenth g^in. The tablet should be dis-
solved on the tongue and not swallowed. The dose may be repeated in
from ten minutes to two hours, according to the effect. If the patient
remains quietly at hwne, in a cool, semidark room, one or two doses will
suffice. If out in the air and dust then a tablet every hour or two may
be necessary. The drug taken by the stomach has little or no effect.
Local application to the nose and eyes are advised. The author sug-
gests that the active principle be made into an ointment, or diluted with
compound stearate of zinc for use in the nose.

In regard to pollatin the author states that its effects are positive in
from thirty to fifty per cent of the cases met with, but in these it is only
palliative, and where the suprarenal preparations are effective pollatin
offers no advantage over them. The nose should be carefully cleansed
before any local medication is employed. Internal medication is con-
sidered and the judicious use of belladonna, or its active principle is
advised in certain cases. The antilithic remedies and mild alkaline
carbonated mineral waters are helpful in some cases. General pre-
cautions, such as change of residence, avoidance of dust, and regulation
of diet are considered. The diet should be a simple one with avoidance
of pastry and sweets.

One very practical point, not mentioned in the paper,, in regard to the
irritation of the eyes is the use of a separate handkerchief for wiping the
eyes. Patients find that the nasal secretion is very irritating, and that
the only way to avoid ^uch irritation is to use a separate handkerchief.

NASAL INSUFFICIENCY.
Doctor Bertrand de Gorsse {Revue Hebdomadaire de Laryn-
gologie, D'Otologie et de Rhinologie, July 28, 1906) calls attention to
the importance of moderate degrees of nasal obstruction and its effects
on the general health.

410 ORIGINAL ABSTRACTS.

The author shows how nasal insuffidency kads to improper develop-
ment of the bones of the face and teeth, and causes a feeble vesicular
murmer. This feeble vesicular murmer is more noticeable during sleep,
when the parts are relaxed and the soft palate falls of its own weight.
The current of air passing through the mouth has to raise the soft palate
before it can enter the larnyx on its way to the lungs. This diminution
of nasal respiration reacts on the general system, by interfering with the
oxygenation of the blood, by facilitating infection through the air
passages, and in other ways. The effect of improper nasal breathing
naturally varies with different periods of life, younger subjects being
more succeptible than adults. The author very properly calls attention
to the fact that adenoids are not the only cause of the classical symptoms
of nasal obstruction. The profession, by being educated to the impor-
tance of adenoids as a cause of nasal obstruction, may have overlooked
the fact that there are other causes that are just as important, though
many times more difficult to recognize. This paper calls attention to
these other causes very forcibly, and urges the necessity of a careful
examination of the whole tract. The intellectual slowness and mental
inaptitude accompanying nasal obstruction, which was named by Guye,
"Aprosexie Nasale," is discussed. Attention is drawn to the impor-
tance of even moderate degrees of nasal obstruction as a factor in the
production of pulmonary consumption, and the work of Lombard is
quoted.

The effect of improper breathing as cause of sinus disease and mid-
dle ear infection is considered. The author advises surgical treatment
in many of these cases, but believes that some of the inflammatory
troubles, such as hypertrophic rhinitis, can be successfully managed by
nonsurgical methods. In the first period of hypertrophic rhinitis the
condition is a simple vasomotor trouble, with congestion of the
mucous membrane and dilatation of the vascular sinuses. If this con-
tinues the walls of the sinuses lose their contractility, and the mucous
membrane passes into the second, or hyperplastic stage, where there
is a true histologic modification of the mucous membrane.

The paper deals with the arthritic diathesis as a factor in the produc-
tion of nasal congestion, and calls attention to the frequency with which
the lower bowel is affected, and the susceptibility of these patients to
atmospheric changes and the ingestion of cold water. The author pre-
fers to call this condition the ''Congestive Diathesis," rather than the
vague term, "Arthritic Diathesis." This tendency to congestion is a
sign of a permanent arterial hypotention of vasomotor origin, depend-
ant upon the nervous system. Medical and hygienic treatment should
be used in these cases, and the patient should practice respiratory
gymnastics.

APPENDICOSTOMY. 411

PROCTOLOGY.

LOUIS JACOB HIRSCHMAN. M. D.

CUMICAX. PSOrSSSOR OV PKOCTOLOGT IN THB DBTKOZT COLLBGB OP MBOICINB.

APPENDICOSTOMY.

TuTTLE, in Jama, Volume XLVII, Number VI, states that the name
appendicostomy was first suggested by Willy Meyer in 1902 to desig-
nate the operation devised by Weir, which consisted in the fixation of
the appendix to the surface of the abdomen and utilizing its calibre and
opening into the cecum for washing out or medicating the colon in
chronic inflammation of this organ.

In describing the technique of the operation Tuttle says that the
cecum should be brought up and stitched to the parietal peritoneum, the
appendix fastened to the lower angle of the wound and the abdomen
closed by layer sutures. The appendix is cut off at the end of two days
at about one-quarter inch from the skin and the opening dilated. A
catheter is then introduced two to four inches, and allowed to protrude
about four inches. It is held in place by a ligature. On the third or
fourth day irrigations are begun.

In amebic dysentery, Tuttle uses normal saline solution at a tem-
perature of 65° to 75° Fahrenheit, although quinin solutions in various
strengths are largely used.

In catarrhal conditions, with or without ulcerations, silver nitrate,
one to five thousand; ichthyol, one-half to one per cent; peroxid of
hydrogen, ten to twenty per cent ; aqueous fluid extract of krameria, ten
per cent, and argyrol, five to twenty-five per cent have all given
satisfaction.

The operation is indicated in all chronic inflammatory diseases of the
colon, particularly in amebic dysentery, muc(Hnembranous colitis, and
syphilitic ulcerations of the colon.

Tuttle has collected seventy-seven cases done for the following con-
ditions :

Amebic colitis 45

Mucous colitis 15

Syphilitic ulceration of colon '. 4

Tubercular ulceration of colon 4

Multiple papillomata 2

Intussusception I

Volvulus I

Chronic constipation 2

Carcinoma tranverse colon I

Hemorrhagic colitis I

In resection of ileum as precaution against gaseous distension i

Results. — In the forty-four cases of dysentery there were six
deaths following, but not due to the operation ; two from unsuspected
tuberculosis, two from extensive ulceration of bowel with chronic

412 ORIGINAL ABSTRACTS.

nephritis, one from exhaustion before the appendix was opened and
one from cerebral disease, three months after the opersrtion, the dysen-
tery having been apparently cured for two months. The balance of
the cases (thirty-eight) are reported cured. Two relapses are reported,
one after two years. In the cases of papillomata the operation was
only palliative, as was also the fact in carcinoma. The cases of
syphilitic ulceration appear to have been greatly benefited, if not perma-
nently cured. In the cases of volvulus and intussusception the
operation was effectual. In the cases of mucous colitis the reports are
all favorable. In these, however, we must consider how much was
due to the removal of the appendix and how much to the effects
of the appendicostomy. The relationship between chronic appendicitis
with adhesions and chronic mucomembranous colitis is a very close
one. By appendicostomy we get rid of the appendix, whether it be
the cause or effect of colitis and at the same time give access to the
parts for local treatment.

NEUROLOGY.

DAVID INGLIS, M. D.

PR0VBS80K or NSKVOUS AKD MBWTAL DISKASSS IK THE DSTHOrT COLLBCB OW MBDICtm

AND

IRWIN HOFFMAN NEFF, M. D.

ASSISTANT PHTSlCtAN AT TBB BASTBUlf MICHIGAN ASTLUM.

"CYTODIAGNOSIS OF ORGANIC PSYCHOSES."

This is the title of an article in the Journal of the Michigan State
Medical Society for July, by Clarence E. Simpson. The author pre-
sents a short review of cytodiagnosis for diagnostic purposes, and gives
details of twenty-five cases of simple and complicated psychoses sub-
jected to lumbar puncture. The author mentions the wide divergence
of technique in estimating the lymphocytes in the spinal fluid, and
describes a technique of his own which has proved practicable. Pre-
sumably from a consideration of his twenty-five cases which were
thoroughly studied the writer formulates the following conclusions:

(i) An increased lymphocyte count denotes meningeal irritation.

(2) No lymphocytosis is present in cases of dementia precox, epi-
lepsy, manicdepressive insanity, or arteriosclerosis.

(3) An increase of the lymphocytes seems to occur only with pare-
sis or tabes, and its presence in a case in which tabes can be excluded is
evidence of paresis.

(4) As. a rule the degree of cellular increase is proportionate to the
amount and rapidity of pathologic change.

(5) A normal lymphocyte coimt is not proof of the absence of
paresis. It may mean only an arrest in the progress of the disease.

L H. N.

MEETING OF BRITISH MEDICAL ASSOCIATION. 4U

EDITORIAL COMMENT.

THE TORONTO MEETING OF THE BRITISH MEDICAL

ASSOCIATION.
The meeting of the British Medical Association, held in Toronto,
August 21-25, was an event of more than ordinary importance.
Through the hospitality of the association, many American physicians
were formally invited, and the generosity of the Canadian members
enabled a great many Americans to get on the program. The meet-
ing of the American Orthopedic Association took many men to Toronto
about the same time and many others concluded that Toronto
would be a good place for part of a summer vacation. Except for the
intense heat, this was true. The meeting was a large one. From the
British Isles and from all parts of the Empire, members came. The
Canadian Medical Association had a small meeting just before, and
its members doubtless stayed over in considerable proportion. The
Tuberculosis Exhibition and a meeting of the Dominion Alliance^— a
temperance organization, perhaps added to the crowd, so that in all a
registration of some twenty-two hundred was secured. Since among
the English members were some of the most conspicuous members cf the
profession — well-known authorities in all departments, — ^the general
effect was that of an international congress, including even diversity of
speech. One was often reminded of t;he sign in Paris stores (or shops,
to be more English) : "English Spoken; Both Kinds." The American
who has heard his speech reviled could gather comfort from the York-
shire, Scottish, or other brogues, that differ from the kind heard in
Mayfa> as much as the speech of Fifth avenue from that of Hester
street.

* * *

Toronto is a good convention city. Well situated, built on a mod-
ern plan, with good hotels and a convenient trolley system, it has room
and facilities. The general effect of the buildings is good, though there
are still too many tumble-down houses on prominent streets. The civic
spirit is illustrated by the fact that funds are being raised for a two-
milHon-dollar teaching hospital. The bay and islands and the beauti-
ful parks furnish easy refuge from city dust and noises. On one of the
islands the Royal Canadian Yacht Club dispensed a royal hospitality, and
sent out sailing parties as often as a wish was expressed. The quarters
of the meeting were as nearly perfect as could be desired. The main
building of the University, a noble pile with its dignity added to by the
broad expanse of lawn over which it is usually approached, served
admirably for the places of registration. The latter were not so exten-
sive, but apparently as efficient as those of the American Medical Asso-
ciation. In the same building were the telephone and telegraph offices,
postoffice, boot-black room, newspaper booth and several section meeting

414 EDITORIAL COMMENT.

rooms. The commercial exhibit in the building was almost as limited as
that of the Boston meeting of the American Medical Association. Most
of the picturesque piles of samples so dear to many were absent, and the
best one could do was to eat patent food ice-cream — ^very refreshing —
and carry away samples of Canadian whiskey. The splendid collection
of Paul Kane's Indian pictures, loaned by Mr. E. B. Osier, formed a
great attraction to the rooms of the exhibit.

4( ♦ ♦

The pathological exhibit was of great interest, containing not only
many specimens familiar to all, but a number of hearts from cases of
Stokes-Adams disease, shown by Doctor G. A. Gibson. The exhibit of
skiagrams was of great interest and very well arranged. Several sec-
tions met in the medical, chemical and other buildings not far from the
main building. In most space was adequate, aside from the heat the
ventilation was good, and above all one missed with pleasure the work
of carpenters, riveters and other noisy trades that seem to hold the
sections of the American Medical Association in thrall.

* 7ti *

The general meeting differed from those to which we are accustomed
chiefly in the use of academic costume by many of the chief participants.
The effect would have been better in a building more adapted to such
purposes than the unfinished and unsatisfactory convocation hall. Of
all the general meetings, the one that excited most interest was the
Oration in Surgery by Sir Victor Horsley on the "Technic of Oper-
ations on the Central Nervous System." In first-hand knowledge of
the subject, and in scope and mode of presentation this was a masterly
address, and should be read by every physician. It was no less inter-
esting on account of the quiet ease of its delivery, every word being
distinctly audible in a building of the most imperfect acoustic qualities.
Sir James Barr's address in medicine, on the "Circulation Viewed from
the Peripheral Standpoint," was very suggestive, but more adapted to
reading than hearing.

♦ ♦ s|c

The work of the sections differed from that usual in the United
States. The number of papers was small; the hours limited to the
mornings of four days. The absence of stenographers seemed a serious
error. It is difficult, if not impossible, to find stenographers who can
take verbatim notes of all medical speakers, and when so taken they
still need correcting. But it is still more difficult for a speaker to sit
down and in the midst of a discussion, or during reading of another
paper, write out his remarks. As my attention was confined to the
Medical Section I shall not attempt to describe the work of others, but
only remark that many of them had important topics under discussion,
and the impression I gathered was that these were generally interesting
and instructive.

This was eminently true of the Medical Section. The first day had
for consideration "Arterio-Sclerosis." As might have been anticipated

MEETING OF BRITISH MEDICAL ASSOCIATION. 415

no new light was thrown upon this timely subject, but a good deal of
clarifying of ideas was indicated by the discussion. ■ A curious incident
was a controversy regarding the tactus eruditus as an interpreter of
pulse tension, or blood pressure. Gibson of course went too far in
giving the impression that the palpation of the pulse is useless, and
Broadbent was equally wrong in making the educated touch the equal
of blood pressure instruments. The second day was devoted to
"Metabolism," and brought out a lively discussion regarding the well-
known views of Chittenden.

The great day was that devoted to the discussion of "Heart-Block,"
and this was one of the greatest sessions, beyond question, of any med-
ical society. The question was opened by Aschoif, who gave a mas-
terly presentation of researches carried on in his laboratory for more
than two years, part of which have been made accessible in the book by
S. Tawara on "Das Reizleitung System des Saugetierherzens." It
seems impossible to doubt that Aschoff and his pupils have carried the
work begun by His immeasurably forward, not only anatomically, in
showing the extensive system of fibres going out from the auriculo-
ventricular bundle, — ^fibres originally described by Purkinje, but whose
real nature and function was hitherto unsuspected. Even more, the
function of the bundle becomes more easy to understand, from the
course and distribution of the fibres. Finally, Aschoff described very
briefly changes observed in rheumatism, causing seemingly specific
nodules, the relations of which to the Purkinje fibres may be of the very
greatest pathologic and clinical importance.

Aschoif delivered his address in English of good quality. His quiet
manner, his still youthful face, looking all the more student-like from the
"handsome" duelling scars, and his evident command of the subject
made a deep impression^ In an adjoining room he had many sections
under microscopes, showing the bundle and fibres in various places, and
rheumatic submiliary foci.

Erlanger gave a very good account of the results of his investiga-
tions, and Mackenzie spoke too briefly of the interpretation of pulse
tracings, in heart-block, and mentioned some instructive examples. G. A.
Gibson showed tracings and hearts with microscopic sections from cases
of Stokes-Adams disease. W. S. Morrow showed a very ingenious
model for demonstrating types of arhythmia, discussed some of
Mackenzie's terms, and Sir James Barr detailed a case history with
some comments on the received explanation of heart-block.

Those who that day heard of heart-block for the first time doubtless
concluded he was hopelessly dense, but his attitude of doubt was quite
natural to anyone who had made even a thorough study before the reve-
lations of Erlanger. To those who knew the latter, and especially to
those who had seen Erlanger's own demonstrations, it seems certain that
he has performed a work that made his appearance a necessary part
when AschoflF and Mackenzie were on the program.

On the last day of section work a number of papers were read,

416 EDITORIAL COMMENT.

including an important one by Flexner on a "Meningococcus Serum ;"
F. J. Smith on "Fuller Feeding in Typhoid;" Spiller on "Syringomy-
elia ;" Dock on "Paracentesis of the Pericardium," et cetera. One thing
that seems worth mentioning is a greater frankness in discussing dis-
puted points, especially striking in comparing the discussion of Chit-
tenden's paper with that of Billings' at the Portland meeting on the
same subject, but in many other cases.

Among the topics discussed in other sections, the "Use of Alcohol in
Treatment," in the Therapeutic Section was perhaps the one most
important to physicians. The general tendency of the speakers seemed
toward a middle course, avoiding the routine use as well as the complete
abandonment of alcohol. At the meeting of the Dominion Alliance, in
which Sir Victor Horsley took a prominent part, the great improve-
ment regarding the use of alcoholic remedies in disease was clearly
brought out. Perhaps it was wholly accidental, but more likely a sign
of the shrewdness of advertising experts, that a Peruna "ad." occupied
a conspicuous position in the account of the meeting of the Alliance.

The social functions were numerous and very attractive. The
garden parties furnished agreeable foci in which to meet one's friends
and see everyone. The dinner was like most functions of that kind —
very agreeable, so long as one could have a quiet talk with his neigh-
bors, but a serious bore when the speakers began, for only a small
minority could hear what was said, while private conversation was out
of the question. On the whole the meeting was most profitable and it is
to be hoped that the British Medical Association will often meet in
America and will be as hospitable as it was this time. Perhaps in time
an Anglo-Saxon Association may grow out of the obvious affinities of
blood and traditions. G. D.

ANNOTATIONS.

SALT-FREE DIET IN SCARLET FEVER.

Pater, a Frenchman, recommends a varied but salt-free diet as a
substitute for the usual absolute milk diet in the treatment of scarlet
fever. The food contemplated in his tests embraced bread, without salt ;
rice ; potatoes ; eggs ; butter ; light desserts ; and milk. While the inges-
tion of these heavy staples in the initial stages of the disease produced
febrile albuminuria, this symptom soon disappeared, and the nutritious
foods proved not only agreeable to the patient but greatly favored the
possibility of offsetting secondary infections and complications, besides
shortening the period of convalescence.

PECULIARITIES OF THE SPIROCUyETA PALLIDA. 417

SOME PECULIARITIES OF THE SPIROCH.ETA PALLIDA.
Beer^ a German investigator, has succeeded in keeping the spiro-
chaeta pallida alive and under observation for a period of thirty-three
days. The organisms were procured from primary lesions, mucous
patches, and buboes. During the specified time no developmental
change was apparent, and no division of the living spirochete was
observed, although the author noticed what seemed to be a longitudinal
fission, with a resulting Y-shaped form. The hanging-drop method of
studying motility was discarded for a common cover-glass and slide
made air-tight with vaselin and wax. Two forms of motility were
observed, namely, rotation about the long axis, and lateral motion of the
entire cell. When the spirochaet^ comes in contact with a cell the rotary
motion is accelerated, and the organism from all appearances endeavors
to penetrate the cell wall. In fresh preparations the organisms imme-
diately attach themselves to the cell membrane, giving a clue to the
possible location of tihe spirochaete in microscopic examinations — the
periphery of blood corpuscles, epithelial cells, et cetera.

BARON TAKAKPS OBSERVATIONS ON BERIBERI.
The remarkable freedom of the Mikado's troops from disease during
the late Manchurian campaign directed the attention of the entire med-
ical world to the excellence of the Japanese sanitary regime. Inasmuch
as bereberi was one of the principal bugbears which the medical officers
of the army were obliged to fight vigilantly, some observations recently
disclosed by Baron Takaki, of the Japanese army, before the Montreal
Medico-Chirurgical Society are worthy of note. In Japan, where the
disease has been known for centuries, it is designated Kak'ke, "leg
trouble." It asserts itself more particularly in the larger cities and older
towns. It is not only peculiar to Oriental climes — Formosa, Corea,
China, Borneo, and the Philippine Islands — but is likewise quite preva-
lent in Brazil and other parts of South America. Beriberi exhibits three
forms — ^acute, subacute, and chronic, the latter manifestation being rel-
atively rare. After investigating climatic and living conditions, occupa-
tion, clothing, et cetera, with negative result. Baron Takaki discovered
that food exerts a marked influence in the prophylaxis and cure of the
malady. When the nien were provided with nitrogenous and carbo-
hydrate foods, in the proportion of one to thirty-two, occurrences of the
disease were rare, but as the nitrogenous food was increased the
disease also increased. Out of one hundred sixty troops provided
with mixed food in unsuitable proportions, sixteen succumbed. Later,
under the same climatic conditions, and with a sufficient supply of rice
and barley, no cases developed, ' while those already ill experienced a
rapid recovery. Under the nitrogenous and carbohydrate fpods in the
proportions specified, bodily weight increased, the disease was almost
absolutely eliminated, and the men were practically oblivious to heat
or cold.

418 EDITORIAL COMMENT.

ANESTHESIA WITHOUT SUBJECTIVE ANNOYANCE.
Gersung, the eminent German surgeon, proffers some novel sug-
gestions regarding obviation of the disagreeable struggles incident to
the production of anesthesia. His method consists in enclosing the arms
and forearms in cuffs of cdluloid which project several inches beyond
the finger tips, thus rendering these members useless insofar as med-
dling with inhaler or anesthetist is concerned. Efforts to gain a sitting
posture are frustrated by having a nurse raise the patient's feet several
inches above the table until total sleep is induced. Without the aid of
the leg muscles the patient is unable to effect the semierect position.
The simplicity of these procedures would seem to commend them for
trial. _________-_^

A PURIFIER FOR THE LACTEAL PRODUCT.
The demand for pure milk as a food staple for infants, has led to the
discovery by Much and Romer of a safe and effective means of
destroying microorganisms in the lacteal fluid. Inasmuch as milk of
tuberculous cattle contains the tubercle bacillus, there is possibility that
other diseases peculiar to the bovine species may also assert themselves
in the secretion. The employment of chemicals renders the milk unfit for
infant feeding, and boiling effects a decomposition of the albuminoid
constituents. Thus these methods are impractical as well as was
hydrogen peroxid as formerly employed, since the milk was rendered
unpalatable. For the purpose of destroying this unpleasant property of
an otherwise excellent agent. Much and Romer, after long experimenta-
tion, discovered that if a sterile vessel containing sufficient hydrogen
peroxid to render the proportion about one to one thousand was
employed as a receptacle in the milking process, excellent results could be
obtained after allowing the fluid to stand from six to eight hours and
then adding a ferment, hemase (which is prepared from the blood of
cattle), in the proportion of 0.5 to one grain per litre of milk. Hemase
acts as a catalyzer and because of its marked affinity for hydrogen
peroxid this agent is entirely removed after a period of two hours, and
the milk rendered tasteless and free from the danger incident to
germ life. —

CONTEMPORARY.

HYPNOTISM : ITS HISTORY, NATURE, AND USE.

HAROLD M. HAYS, OF THB COLLBGB OF FHYSICIANS AMD SURGhONK, NBW YOKK CITY, IN THB POrULAR

BCIBNCB MONTHLY ]

( Continued from page 3S1)

In 1866 this M. Ch. Lafontaine, a traveling mesmerist, published
his "Memoirs of a Magnetizer." If it had not been for this, the electro-
biologists of America, under one named Grimes, might have claimed
prior right to the discovery of hypnotism. M. Lafontaine thus describes
the state of affairs at that time :

HYPNOTISM. 419

''Having accomplished the cure of numerous deaf and blind persons,
says he with modest assurance, as also numerous epileptic and paralytic
sufferers at the hospital (this was in Birmingham), I repaired to Liver-
pool, but only to meet with disappointment ; few persons attended the
seance ; and on the following day I proceeded to Manchester in which
city my success was conspicuous. The newspapers reported my experi-
ments at great length, and to give some idea of the sensation I created,
I may say that my seances returned me a gross total of thirty thousand
francs. I put to sleep a number of persons who were well-known
residents of Manchester. I caused deaf mutes to hear, operated a
number of brilliant cures. After my departure, I>)ctor Braid, a surgeon
in Manchester, delivered a lecture in which he proposed to prove that
magnetism was nonexistent. From this lecture Brcddism, aftenvards
called hypnotism, originated, ardent discussion arising, even from the
beginning over this pretended discovery. I received letters from Man-
chester entreating me to return, and I did so on a date when Doctor
Braid had announced a demonstration. His experiments were given,
but unfortunately, on this occasion none of them succeeded; neither
sleep nor catalepsy was obtained, and every moment I was appealed to.
In the facts that were advanced on this occasion by Doctor Braid, there
was in my opinion, absolutely nothing that was remarkable, and had
not that gentleman been honorably known in the town, I should have
supposed that he was mystifying his audience. The next day, and for
six days consecutively, I experimented after his own fashion on fifty
or sixty subjects and the results were practically nil, I then gecvt a
magnetic seance and the results on Eugene and Mary were marked and
positive."

The value of the quotation rests solely on the opportune remark that
Braid was the first to apply the name hypnotism to animal magnetism.
One should not forget that Eugene and Mary were two subjects whom
Lafontaine carried with him from town to town and on whom he could
rely for phenomena.

Though Braid survived his discovery by not more than eighteen
years, he lived to know that it was well on the road to acceptance by
the competent opinion of the time. In the latter part of his life he said,
"I feel no great anxiety for the fate of hypnotism, provided it only has
'a fair field and no favour.' I am content to bide my time, in the firm
conviction that truth for which alone I most earnestly strive, with the
discovery of the safest, and surest, and speediest modes of relieving
human suffering, will ultimately triumph over error" ("Magic, Witch,"

page 53)-

The enemies of Braid were as vociferous in their denunciation of
him as his friends were earnest in their praise. And what may seem
the greatest surprise and yet what seems to be a natural consequence
of opposition, the mesmerists themselves were the ones who were the <

loudest in opposing him. However, his method has stood the test of i

years and still prevails among those who practise the art nowadays. . j

420 EDITORIAL COMMENT.

As was said before, the first exhibition that Braid ever attended was
one given by this same Lafontaine. One fact, the inability of the
patient to open his eyelids, arrested his attention. He considered this
a real phenomenon and was anxious to discover the physiological cause
of it.

*'In two days afterwards," he says, "I developed my views to my
friend, Captain Brown, as I had previously done to four other friends ;
and in his presence and that of my family and another friend, the same
evening, I instituted a series of experiments to prove the correctness of
my theory — namely, that the continued fixed stare, by paralyzing
nervous centers in the eyes and their appendages arid destroying the
equilibrium of the nervous system, thus proved the phenomenon referred
to. The experiments were varied so as to convince all present, that
they fully bore out the correctness of my theoretical views. My first
object was to prove, that the inability of the patient to open his eyes
was caused by paralyzing the upper muscles of the eyes, through their
continued action during the protracted fixed stare, and thus rendering
it physically impossible for him to open them. With the view of proving
this, I requested Mr. Walker, a young gentleman present, to sit down,
and maintain a fixed stare at the top of a wine bottle, placed so much
above him as to produce a considerable strain on the eyes and eyelids,
to enable him to maintain a steady view of the object. In three minutes
his eyelids closed, a gush of tears ran down his cheeks, his head drooped,
his face was slightly convulsed, he gave a groan and instantly fell into
a profound sleep, the respiration becoming stow, deep and sibilant, the
right hand and arm being agitated by slight convulsive movements.
At the end of four minutes, I considered it necessary, for his safety, to
put an end to the experiment."

Braid became so convinced that his interpretation of the phenomena
was the correct one that he used it universally, succeeding in a remark-
able number of cases. His method was as follows :

He would take any bright object, most often his lancet case, and
holding it about fifteen inches from the eyes and in such a position as
to strain them and still allow the patient to gaze steadily at it, he would
carry it slowly toward them until the eyelids closed involuntarily. After
a preliminary contraction of the pupils, they would dilate, and finally
a tremulous motion of the iris would take place. H this did not suc-
ceed after a few minutes, he would try again, letting the patient under-
stand that his eyes and mind had to be riveted on the one idea of the
object before him. The primary fact was the fixation of the mind on a
certain object. Nay, even the hypnotist himself, if he use the method
of attraction, may be hypnotized, as Braid shows in the following
example. Mr. Walker, Braid's friend, offered to hypnotize a certain
person. When Braid went into the room where the experiment was
going on, he saw the gentleman sitting staring at Mr. Walker's finger.
Mr. Walker was standing a little to the right of his patient with his
eyes fixed steadily on those of the latter. Braid passed on, and when

HYPNOTISM. 421

he returned he found Mr. Walker standing in the s^me position fast
asleep, his arm and finger perfectly rigid and the patient wide awake,
staring at the finger all the while.

After Braid, many men pursued the scientific investigation of the
phenomena. The interest in the new science since 1875 has spread
quickly over Europe. In Belgium, the eminent psychologist, Delboeuf
of Liege, made a path for it. In Holland such men as Van Reuterghem,
VanEiden and. De Jong used hypnotism for curative purposes ; in Den-
mark, Norway and Sweden, there were Johannessen, Sell, Frankel,
Calsen and Wetterstrand, of Stockholm, and finally Swedenborg. In
Russia were Strembo and Tokarski ; in Greece, Italy and Spain, hypnot-
ism has greatly come into play in medical treatment. In England,
Carpenter, Laydock, Sir James Simpson, Lloyd"-Tuckey, Mayo and
others have used it for curing the sick. In America, the science also
has its advocates. It is one of the subjects constantly appea^ring before
the Society for Psychical Research. In South America, it numbers
among its adherents, David Benavente and Octavio Maria, of Chili.
The interest in hypnotism in France centered around two schools, the
school of Salpetriere and the school of Nancy. The former was led by
Charcot, whose luminous researches in this subject are epoch-making.
The Paris school held that hypnotism is the result of an abnormal
or diseased condition of the nervous system ; that suggestion is not at
all necessary to prodtice' the phenomena ; that hysterical subjects are
the most easily influenced; and that the whole subject is explainable
on the basis of cerebral anatomy and physiology. But lately the fol-
lowers of Charcot, who had been numerous in the beginning because
he was so highly reliable a man, have begun to dwindle away and have
turned to the school of Nancy. The reason for this is obvious, to any
one who has studied hypnotic phenomena. The first objection to the
school of Salpetriere is that most of the experiments have been made
on hysterical women. In the second place, this school ignores sugges-
tion, which has been found to be one of the most important factors in
hypnotism. They appreciate of course that it can be used, but assert
that it is not necessary.

The school of Nancy, led by Bemheim, met with equal success and
is now upheld by more people than the other school. The theory of the
school of Nancy may be summed up in a few words : first, the different
psychological conditions in the hypnotic state are determined by mental
action; secondly, people of good sound physical health and of perfect
mental balance can produce the best results ; and thirdly, all the mental
and physical actions are the result of suggestion. In fact suggestion
is the all important factor in producing the various phenomena.

Liebault, and Bemheim, his pupil, by bringing forth the idea of
suggestion, have made themselves in a way the equal of Braid, for in
continuation of the latter's method, the method of the former is always
used nowadays. The influence of Bemheim over his patients is remark-
able. His great success may be accounted for by the confidence his

4tt MEDICAL NEWS.

patients have in bim« Of course the low intellectual state of the peasant
class of France may have something to do with it, for one can hardly
think that in any ordinary community this supreme belief and tnist
in a human being could exist. To Nancy people come from all over
the provinces to visit this "Man of God/' who performs experiments
and cures which seem divine. Bemheim goes from one patient to
another, shouting "sleep." Many of them having been hypnotized b}
him often fall into the state immediately. When the experiments are
over he goes the rounds of his patients, snapping his fingers, in which
way he awakens them.

To sum up then, we may say the history of hypnotism may be
divided into five epochs. The first before the time of Mesmer; the
second, the age of Mesmerism, when personal magnetism was supposed
to be the attractive power ; the third, the age of Braid, when the science
was put on. a physiological basis ; the fourth, the age of Bernheim and
Charcot, when the idea of suggestion was brought to the front and
hypnotism was used indiscriminately; and lastly, the fifth, the age we
are in now, where the tendency is to restrict hypnotism and to classify
it for specific uses. j„ „ co»«w»d.]

MEDICAL NEWS.

ARKANSAS MEETING OF VALLEY ASSOCIATION.

The Mississippi Valley Medical Association will convene in thirty-
second annual meeting at Hot Springs, Arkansas, on November 6,
1906, under the presidency of Doctor J. Henry Carstens, of Detroit, and
continue its sessions for three days. The preliminary program
announces a large number of valuable papers on the various phases of
medicine and surgery. Doctor Frank Parsons Norbury, of Jadcsonville,
Illinois, will deliver the Oration in Medicine, his subject being "Clinical
Psychology ;" and the Oration in Surgery, by Doctor Florus F. Law-
rence, of Columbus, Ohio, will contemplate "Surgical Principles and
Theories." Elaborate arrangements have been made by the local pro-
fession of Hot Springs to entertain visiting doctors and their wives.
Every physician resident in the Mississippi Valley is cordially invited to
attend the meeting, and those desiring to present papers may com-
municate with the Secretary, Doctor Henry E. Tuley, iii West Ken-
tucky avenue, Louisville, Kentucky. Following is the list already
announced :

Charles E. Barnett, Fort Wayne, Indiana — "Operative Necessities
for Cure in Tuberculous Orchitis ;" J. H. Barnett, Pikeville, Tennessee
— ^"Gall Stones : Reports of Two Cases ;" John M. Batten, Downing-
ton, Pennsylvania — "Strength;" H. M. Beaver, Ocheltree, Kansas —
"Tuberculosis, its Prevention and Treatment as viewed by the Medical

ARKANSAS MEETING. 423

Profession and the Laity — A Special Study ;" G. G. Buford, Memphis,
Tennessee — "True Cause of Functional Neuroses ;" James B. Bullitt,
Louisville, Kentucky — "Appendicitis, the Imperative and the Alter-
native;" V. P. Blair, Saint Louis, Missouri — "Etiology, Pathology,
and Operative Treatment of Deformities of the Face and Mouth Due
to Malrelations of the Jaws ;" J. B. Bolton, Eureka Springs, Arkansas
— "Some Suggestions of Importance to Organized Medicine;" Geo.
F. Butler, Chicago, Illinois — "Constipation and its Treatment ;" A. H.
Cordier, Kansas City, Missouri — "Non-Lkhogenous Obstruction of
Biliary Ducts;" Geo. C. Flippin, Pine Bluff, Arkansas — "Surgery of
the Gall-Bladder;" R. D. Garcin, Richmond, Virginia— "The Obstet-
rical Forceps: Their Indications and Contraindications;" W. Gavis,
Canton, Ohio— "Lithemia ;" Frank W. Glenn, Nashville, Tennessee —
"Prevention and Treatment of Gonorrhea;" Howell B. Gwin, Nash-
ville, Tennessee — "Epididymitis in Patient Presenting Three Testes
and Double Penis — Showing Patient ;" D. M. Hall, Memphis, Tennes-
see— "Report of Case of Acute Toxemia of Pregnancy ;" Earl Harlan,
Cincinnati, Ohio— "Partial Intestinal Obestruction ; Its Causes, Symp-
toms, and Surgical Treatment ;" M. L. Heidingsfeld, Cincinnati, Ohio —
"Paraffin Prosthesis : Its History and Other Considerations ;" Marc Ray
Hughes, Saint Louis, Missouri — "Epiplesy;" C. H. Hughes, Saint
Louis, Missouri — "The Entoning of the Psychic Neurons in Neuro-
therapy and in General Therapeutics;" J. E. Johnson, Memphis,
Tennessee — "Prosthetic Surgery of the Face;" J. L. McGehee, Mem-
phis, Tennessee — "Stones of the Common Bile Duct;" E. H. Miller,
Liberty, Missouri — ^"'Masked Typhoid Fever;" Frank Parsons Nor-
bury, Jacksonville, Illinois — ^"Clinical Psychology ;" Wm. Porter, Saint
Louis, Missouri — "Tuberculosis : A Personal Appeal ;" H. A. Rodebaugh,
Columbus, Ohio — "An Explanation of the Formation of Drug Habits ;"
H. J. Scherck, Saint Louis, Missouri — ^"Bladder Surgery;" John N.
Sluss, Indianapolis, Indiana — "The Diagnosis and Treatment of Brain
Traumatisms ;" F. D. Smythe, Memphis, Tennessee — "Volvulus of the
Omentum, Intra-abdominal ;"W. A. Spitzley, Detroit, Michigan — "Rea-
sons for the More General Use of Local Anesthetics and the Methods
of Employing Them;" Sterling B. Taylor, Columbus, Ohio — "Hem-
orrhoids, Post of Treatment;" Willis Walley, Richton, Mississippi —
"Typhoid Fever, with Treatment;" Madison J. Walton, Memphis,
Tennessee — "Report of Cases of Probable Maternal Impressions;"
W. H. Wathen, Louisville, Kentucky — "Drainage in Surgery of the
Gall-Bladder and Bile Ducts;" T. J. Watkins, Chicago, Illinois— "Blunt
Dissection in Plastic Gynecologic Operations;" R. W. Webster, Chi-
cago, Illinois — "Indications for and Effects of Over-feeding and Under-
feeding ;" T. C. Witherspoon, Saint Louis, Missouri — "Bowel Obstruc-
tion;" C. M. Capps, Knoxville, Tennessee — "Foreign Bodies in the
Throat, with Report of Cases ;" Wm. Britt Bums, Memphis, Tennessee
— "Head Injuries;" Maynard A. Austin, Anderson, Indiana — "The Per-
sonal Element in Successful Surgery;" W. W. Robertson, McComb,

424 MEDICAL NEWS.

Mississippi — "Periostitis, Surgical Treatment;" Florus F. Lawrence,
Columbus, Ohio — "Surgical Principles and Theories ;" C. N. Harrison,
Little Rock, Arkansas — "Modem Medicine ;" LH.CCoc^, Hattiesburg,
Mississippi — "Typhoid Fever ;" Richard A. Barr, Nashville, Tennessee
— "Undescended Testicle;" A. A. McClendon, Marianna, Arkansas —
"Report of Case of Amebic Dysentery : Abscess of Liver and Appendi-
citis ;" W. A. McKinley, Columbus, Ohio— "Deep Abscesses Following
Furunculosis ;" M. Goltman, Memphis , Tennessee — "Gall-Bladder
Diseases and Floating Kidney;" Channing W. Barrett, Chicago, Illi-
nois— "A Consideration of Retro-versio-flexions in their Relation to
Pregnancy;" Geo. F. Suker, Chicago, Illinois — "Clinical Data — Diag-
nostic— Concerning Ocular Tumors ;" Quitman Kohnke, New Orleans,
Louisiana — "Yellow Fever and Mosquitoes in New Orleans in 1905 ;"
E. G. Epler, Fort Smith, Arkansas — "Specific Treatment of Pulmonary
. Tuberculosis ;" Geo. Homan, Saint Louis, Missouri — "The Danger of
Dust as a Cause of Tuberculosis;" Wm. Porter, Saint Louis, Mis-
souri— "The Tuberculosis Question;" C. C. Stephenson, Little Rock,
Arkansas — "Trachoma ;" John W. Selman, Greenfield, Indiana — ^''Idio-
pathic Epilepsy, its Course," et cetera; Alex. Weiner, Chicago, Illinois
— "Modern Treatment of Surgical Tuberculosis;" Hugh T. Patrick,
Chicago, Illinois — "Remarks on Combined Degeneration of the Spinal
Cord;" M. Rosenthal, Cape Girardeau, Missouri — "Malaria: Its Bear-
ing on Life Insurance in the Mississippi Valley;" Emory Lanphear,
Saint Louis, Missouri — "Hyoscine-Morphine-Cactin Anesthesia as a
Substitute for Ether and Chloroform in Major Surgery ;" E. B. Mont-
gomery, Quincy, Illinois — "Pubiotomy and its Relative Indications;"
S. T. Rucker, Memphis, Tennessee — "Hysteria : With Report of Case
of Hysteria Major in Woman Sixty-four Years Old." The following
have promised papers: Spencer Graves, Saint Louis, Missouri;
T. M. D- Qarke, New Orleans, Louisiana; B. G. Henning, Memphis,
Tennessee; Bransford Lewis, Saint Louis, Missouri; F. D. Kendall,
Columbia, South Carolina ; J. H. Stucky, Lexington, Kentucky ; Curran
Pope, Louisville, Kentucky ; Robert Wallace Hendon, Chicago, Illinois ;
D. A. Ledbetter, New Orleans, Louisiana; Wm. N. Wishard, Indian-
apolis, Indiana; E. D. Fenner, New Orleans, Louisiana; O. H.
Elbrecht, Saint Louis, Missouri ; Francis Reder, Saint Louis, Missouri ;
Morgan Smith, Little Rock, Arkansas ; S. C. Stanton, Chicago, Illinois.

MINOR INTELLIGENCE.

FoRDHAM University is to be enriched in a literary way by the
donation of the Thomas Addis Emmett Library.

Sixteen physicians occupy seats in the Russian Duma. The entire
legislative body consists of four hundred sixty members.

Allegheny, Pennsylvania, is to have a two hundred fifty thousand
dollar hospital, with accommodations for one hundred twenty patients.

MINOR INTELLIGENCE. 426

A POSTGRADUATE school in gastrointestinal diseases has been estab-
lished in Brooklyn in connection with the Brooklyn Central tHspensal^.

Doctor Willis S. Anderson, of Detroit, announces the removal of
his office to the Washington Arcade, 255 Woodward avenue. Room 511.

The Harvard Club of Michigan has elected Doctor Walter P.
Manton, president, and Doctor Reuben Peterson, vicepresident for the
current year.

Saint Louis is now operating a city tuberculosis clinic at the corner
of Eleventh and Chestnut streets. Treatment is proffered gratis to the
worthy poor.

The Walter Reed Army Hospital, so designated in honor of the dis-
coverer of the etiologic factor of yellow fever, is in process of erection
at Washington.

The inmates of the hospital for the insane at Terrell, Texas, are
suffering from an epidemic of cholera morbus. More than four hun-
dred cases are under treatment.

At the recent Boston meeting of the American Association of
Librarians, Doctor George Dock, of Ann Arbor, was elevated to the
presidency of that organization.

The honorary degree of Doctor of Laws was conferred on Doctor
William J. Mayo, president of the American Medical Association, on
August 24, by the University of Toronto.

The King of Portugal has conferred a Commandership in the Order
of Christ of Portugal on Doctor Alexander Hugh Ferguson, of Chicago,
in recognition of his contributions to surgery.

The library of the late Doctor Weigel, the Rochester radiologist
whose death resulted from bums received while administering the rays,
is bequeathed to the Reynolds Library of that city.

Professor Koch, the eminent investigator, who was recently
awarded the Nobel prize for scientific research, has decided to apply the
sum to the publication of a complete edition of his writings.

The new Minor Private Hospital, of Seattle, was recently opened
for the reception of patients. The institution has capacity for forty-five
patients and is under the direction of Doctor George W. Hawley.

Boston is to have a Pasteur Irfstitute in connection with the City
Hospital. Heretofore Bostonians suffering from rabies have been com-
pelled to journey for treatment to New York, this being the nearest
station.

Major John M. Banister, of the United States Army Medical
Service, says that scarlet fever, diphtheria, and yellow fever are not
indigenous to the Philippine Islands, and adds that during three years
spent in the archipelago he did not observe a single case of these
diseases.

416 MEDICAL NEWS.

A RAILROAD hospital is to be established in Temple, Texas, by the
Atchison, Topeka and Santa Fe Railroad Company. The contract will
be let shortly for the construction of buildings to cost approximately
$65,000.

The annual meeting of the Chicago Physicians' Club was held oa
June 26. The following officers were elected : Chairman, Doctor William
T. Belfield; secretary. Doctor Charles H. Micks; treasurer. Doctor
Arthur M. Corwin.

The honorary title of Professor of Medicine has been conferred on
Doctor Tada Urata by the Japanese government. Miss Urata was the
first Japanese woman to receive the degree of Doctor of Medicine from
a German institution.

''A BILL for an act requiring physicians to take human life" was
recently introduced into the legislature of Iowa. Many euthanasia bills
bave been framed in the past, but the injunction embodied in this title is
indeed presumptuous.

The New York Infirmary for Women and Children, located on
Stuyvesant Square, is to have a seven-story annex, the present accom-
modations being vastly inadequate. Plans are already in the hands of
the building department.

A TUBERCULOSIS cliuic has been inaugurated at Los Angeles in con-
nection with the medical department of the University of Southern Cali-
fornia. Treatment is free of charge, the main object of establishment
being to enlighten people on prophylaxis.

The water department of New York City has requested bids for
constructing an experimental filtration plant for the Jerome Park reser-
voir, the movement contemplating adoption of the cheapest and most
practical means of filtering the city's water.

Hong Kong has suffered severely this year from plague. Since
January, eight hundred seventy-five cases and eight hundred eighteeir
deaths have been reported. However, since May, when as high as one
hundred sixteen cases per week were recorded, the disease has evidenced
a steady decline.

The Belilios prize for scientific research has been awarded to Joseph
Herbert Ford, Captain and Assistant Surgeon in the United States
Army, for his paper on "The Treatment of Dysentery." J. C. Berne of
the Royal Army Medical Corps received second prize for his paper on
the same subject.

The medical license of James G. Stewart, of Seattle, was recently
revoked by the Washington State Examining Board. The charge cited
that this individual conspired with O. V. Lawson to obtain the ques-
tions for a coming medical examination in order that the latter might
fraudulently obtain a license. The defendants were fined five hundred
dollars each in the courts.

MINOR INTELLIGENCE. 427

At a recent meeting of the Southwest Virginia Medical Society, a
resolution was unanimously adopted to the effect that henceforth phy-
sicians should determine the f^ in life insurance examinations, and five
dollars was stipulated as the minimum charge for examinations wherein
urinalysis is required.

Mrs. Ferdinand Reese, who died recently at La Porte, Indiana,
was an example of the effects of careful and abstemious living. Her
reputed age was one hundred twelve years and personal documents
bear evidence that she first saw light at Volgavitz, Poland, in 1794^
She came to America in 1870.

Doctor C. B. Burr, medical director of Oak Grove Hospital, Flint,
Michigan, retiring president of the American Medico-Psychological
Association, was elected to represent that body on the executive com*
mittee of the American Congress of Physicians and Surgeons which
meets in Washington next year.

Plans for a new city hospital have been accepted by the Board of
Public Works of Grand Rapids, Michigan. The hospital will be
devoted mainly to the care of those suffering from contagious diseases.
The building will be three stories in height and the specifications call for
completion before the advent of winter.

Doctor Robert L. Kennedy, of Detroit, has been appointed to the
superintendency of the Michigan State Tuberculosis Sanatorium. The
doctor is a graduate of the Detroit College of Medicine, class of 1898.
In the event that the present plans materialize, the institution will be
ready for occupancy by January i, 1907.

The American Congress of Tuberculosis will meet in New York
City on November 14, 15 and i6> 1906. The United States is taking an
active interest in the event, Honorable Elihu Root, Secretary of State,
having instructed the diplomatic officials of the government to aid and
support the cause espoused by this Congress.

The Crippled Children's East Side Free School Society, of New
York City contemplates the erection, at 643 and 645 Water street, of a
. five-story school building. The structure, which will cost in the neigh-
borhood of $75,000 will be of brick and ornamental stone, and will
be one hundred one feet long by fifty feet front.

The following appointments have been made at the Baltimore Col-
lege of Physicians and Surgeons : Professor of principles and practice
of medicine. Doctor William F. Lockwood; professor of therapeutics
and clinical medicine. Doctor John Ruhrah ; prof efssors of clinical medi-
cine. Doctors Cary B. Gamble and Harvey B. Beck.

The British Medical Association which convened at Toronto last
month is, with the exception of the Anierican Medical Association, the
largest medical organization in the world. Its membership list num-
bers twenty thousand names, and its official organ, the British Medical
Journal, has a circulation of twenty-three thousand.

428 MEDICAL NEWS.

For the purpose of procuring physiological data at various altitudes,
Doctors T. Chalmers Fulton and Samuel J. Ottinger, of Philadelphia,
recently ascended in a balloon to a heighth of nearly four miles. The
gentlemen were suspended in the air for over five hours, and their
observations will rfiortly be given to the medical profession.

A PHYSICIAN in the insane asylum at Claremont, France, wa»
seriously injured in a recent fracas with an inmate, who strucic him
with a piece of bottle. The cunningness of which the insane are capable
was displayed in the concealment of red pepper by the malefactor, which
he threw into the eyes of those who came to assist his victim.

Professor Koch, who has been conducting researches on sleeping
sickness in South Africa,, stated recently that the disease is not
amenable to treatment. He thinks, however, that the extermination
of the insect of transmission, which can be accomplished by burning
the underbrush in which it propogates, will eradicate the disease.

Dover, New Hampshire, is to have a new hospital. The acqui-
sition is rendered possible by a magnanimous bequest of the late Arioch
Wentworth, after whom the institution will be named. The structure
will be of brick, two stories in height, and will cost approximately
$100,000. Accommodation will be afforded for one hundred patients.

The extermination of mosquitoes from Staten Island has been
effected through the efforts of Doctor Doty, health officer of the Port
of New York. Twenty square miles of salt marsh land have been
drained and rendered free from dampness. The achievement is
remarkable in view of the fact that only $17,000 was appropriated for
the work.

Doctor Daniel LaFertI:, of Detroit, has been honored recently
by the French government. In recognition of his promulgation of the
French language and his impersonation of Cadillac at the two hundred
and fiftieth anniversary of the founding of Detroit, he has been pre-
sented with the insignia and medal of the French Academy of the Arts
and Sciences.

British Columbia is to have a new sanatorium for the treatment
of tuberculosis. Several sites are under consideration, but in all prob-
ability one near Kamloops will be selected. The institution is depend-
ent entirely upon popular gift for its erection, but as interest in the insti-
tution is rife there is reason to believe that a sufficient sum will shortly
be subscribed.

Doctor Rolland Farmeter, formerly of Albion, Michigan, but who
has been pursuing special work at the University of Michigan and Euro-
pean clinical centres for the past three years, has decided to engage in
the practice of gynecology and obstetrics in Detroit, and has secured
offices in the Fine Arts Building. Doctor Parmeter is a new adjunct to
the editorial staff of this journal, and in the present issue makes his
debut as associate collaborator in the department of "Obstetrics."

MINOR INTELLIGENCE. 420

The new building of the Atlanta College of Physicians and Sur-
geons, which is being erected at a cost of $75,000, will be ready for
occupancy for the fall term. Andrew Carnegie has donated a sufficient
sum to the college to assure the remodeling of the old Southern Medical
College building, which will henceforth be known as the Carnegie
Pathological Institute.

Arrangements for perfecting the organization of the proposed
Medical Association of the Southwest are about completed. The Com-
mittee on Organization will meet at Oklahoma City on October 30 and
31 in connection with the meeting of the Tri-State Medical Society of
Oklahoma, Texas and Arkansas. The temporary secretary is Doctor
Fred H. Clark, of El Reno, Oklahoma.

The Health Department of New York City was recently sued for
$30,000 by a milk company of that metropolis, which contended that
its business had been destroyed by a revocation of its licenses. The
board held that inasmuch as the dairies were in an unhygienic condition
and the milk unwholesome and adulterated the annulment was justifi-
able, and the court sustained the contention.

The Association for Improving the Condition of the Poor contem-
plates the erection of a two hundred fifty thousand dollar hospital on the
water front in the vicinity of Brooklyn for the treatment of children
suffering from tuberculosis of the bones and glands. Of this amount
John D. Rockefeller gave one hundred twenty-five thousand dollars and
a like sum was raised by popular subscription.

Agitation is rife in Kansas regarding the establishment in one of
the Western counties of a sanatorium for the treatment of tuberculosis,
and it is likely that the next legislature will be asked to make an appro-
priation for the purpose. The recent announcement of the secretary of
the State Board of Health shows that tuberculosis figures more con-
spicuously in the death rate than any other disease.

Admirable work is being done by the New York Society for Im-
proving the Condition of the Poor. A receijt announcement discloses the
fact that thus far four thousand outings of ten days' duration have been
provided for women and children, besides eighteen thousand outings of
one-day duration. Junior Sea Breeze, the open-air camp for sick babies
under the society's control has also done good work in the direction of
caring for deformed and indigent infants.

The organization of a Women's Medical Club has been eflfected at
Seattle, Washington. Meetings are held monthly and the following
officers will guide the destiny of the society during the present year:
President, Doctor Sarah J. Dean; vice-president. Doctor Sarah Ken-
dall; secretary and treasurer. Doctor Marietta Marsh. The other
members of the guild are Doctors Mildred Purman, Fredericka Phillips,
Frances Raberge, Mary A. Downer, Cora Turner Saxe, Agnes B. Har-
rison, Harriet J. Clark, Mary D. Skinner, Minnie Allison, Maud Parker,
Marmora DeVoe and Cora Smith Eaton.

430 MEDICAL NEWS.

A NEW hospital car has been added to the medical equipment of the
Erie Railroad. The car, which is sixty feet long, comprises two com-
partments— an operating room fifteen feet ten inches in length, and a
ward forty-three feet ten inches in length. In the operating room are
operating tables, sterilizers, instruments, and dressing materials. The
ward furnishes accommodation for eleven persons.

The Hague was the scene of this year's International Tuberculosis
Congress, which oxivened on September 6 under the presidency of M.
Bourgeois, the French Foreign Minister, and in the presence of Prince
Henry of the Netherlands. The discussion of September ^ con-
templated the establishment of popular sanatoria. Among the American
speakers was Doctor Lawrence F. Flick, of Philadelphia.

Nine thousand two hundred twelve persons met violent death in
the United States during 1905, an increase of seven hundred thirty over
1904. Three thousand one hundred forty-two of this number were
killed in railroad accidents, and the street railways were responsible for
four hundred sixty-four. Our homicide rate is nine times greater than
that of the Germans, and four times that of the English.

The American Orthopedic Association held its twentieth annual
meeting at Toronto, Ontario, on August 20-23, 1906. The following
officers were elected for the ensuing year : President, Doctor Joel E.
Goldthwait, Boston; vicepresidents, Doctor Henry Ling Taylor, New
York, and Doctor Ansel G. Coc^, Hartford, Connecticut; secretary,
Doctor Robert B. Osgood, Boston ; treasurer, Doctor Elliott G. Brackett,
Boston.

Work on Buffalo's new Children's Hospital, the erection of which
was facilitated by a bequest of the late Doctor DeVillo W. Harrington,
will shortly be commencd, a site having already been procured. Since
the gift of the doctor, which amounts to $75,000, is to be shared with
the General Hospital, of Buffalo, it is not yet known what expenditure
will be possible, and definite plans for the structure have not yet been
adopted.

The report of the San Francisco Board of Health to the California
State Board of Health discloses the fact that four hundred fifty-two
lives were lost in the earthquake. Of these, one hundred seventy-
one perished by fire, seven were shot and two died as the result of
ptomain poisoning. Four hundred twenty of the victims were white,
eighteen were Chinese, four were Japanese, and ten were unidentified as
to nationality.

Some interesting figures were disclosed by the Japanese minister of
war at a recent banquet of representatives of the medical service. At
one time during the late campaign the Mikado had one million two
hundred thousand troops in the field. Of this number three hundred
ten thousand were wounded or sick and seventy thousand died. How-
ever, only fifteen thousand died of sickness, and nine thousand eight
hundred died of wounds after receiving treatment.

MINOR INTELLIGENCE. 431

The corner stone of the Missouri State Sanatorium for the Treat-
ment of Incipient Tuberculosis, located at Mount Vernon, was laid on
August 15, under the auspices of the Knights Templar and other
Masonic orders. The address of the occasion was delivered by Doctor
William Porter, of Saint Louis, who congratulated the state upon its
awakening to the necessity of such an institution. Governor Folk also
addressed the multitude.

Notwithstanding the ordinary tribulations of medical journalism
occasional exigencies arise to encumber the situation. The latest is a
canvasser who has, without authority, been soliciting subscriptions for
Surgery, Gynecology and Obstetrics, So clever was this fakir that in
many instances doctors were persuaded to issue checks payable in his
name. The profession is warned against yielding collateral to solicitors
unable to produce credentials.

Doctor Mary Putnam Jacobi, wife of Doctor Abraham Jacobi,
New York's eminent physician, died on June 10, 1906, aged sixty-three
years. Doctor Jacobi inaugurated her scientific career by receiving a
pharmacal degree in New York, and later (1861) graduated from the
Woman's . Medical College of Philadelphia. In 1871 she graduated
from the School of Medicine of Paris. For many years she was a
prominent physician of New York City.

The following appointments have been made to Johns Hopkins fac-
ulty: Professor of pharmacology and physiological chemistry, Doctor
A. S. Lovenhart; associate professor of bacteriology and lecturer on
hygiene. Doctor William W. Ford ; associate professor of art in its rela-
tion to medicine. Doctor Max Broedel ; instructor in anatomy, Doctor *
A. W. Myer; instructor in pathology, Doctor G. H. Whipple; and
instructor in physiology, Doctor J. A. English.

The necessity for a leper hospital iA the United States is apparent,
and it is reported that Surgeon-General Wyman, of the Public Health
and Marine Hospital Service is endeavoring to obtain an appropriation
ior its establishment. Notwithstanding a bill appropriating $250,000
toward the project passed the last Senate, it failed of passage in the
House because of the opposition of a delegate from New Mexico, who
feared that the buildings would be erected in his state. It is to be hoped
that the renewed efforts will meet with success.

The apprehension of an imposter who claims to be a pupil of Lorenz,
of Orthopedic fame, is desired by the officials of New Jersey. The
swindler has been operating among the poorer classes, and succeeded in
securing a considerable sum of money before his methods were detected.
After gaining charge of a case he would manipulate the deformed mem-
ber, simulating the movements of the great specialist, and then leave a
bottle of liniment, promising to return and administer further treat-
ment. The fee was demanded in advance and the charlatan always
bailed to appear a second time.

432 RECENT LITERATURE.

Providence seems to have spared many of the medical institutions
of stricken San Francisco. Cooper Medical College, and Lane Hospitiil,
which is in affiliation therewith, were but slightly damaged and the
operation of both institutions will not be materially hampered. The
medical department of the University of California and Children's Hos-
pital suffered no serious damage, and although the College of Phy-
sicians and Surgeons was destroyed, its new building will be ready for
occupancy at the opening of the fall term.

RECENT LITERATURE.

REVIEWS.

A MANUAL AND ATLAS OF DISSECTION.*
This work is an illustrated augmentation of "Yutzy's Dissection
Guide." It is such a vast improvement on the former publication, how-
ever, and withal so comprehensive in character, that the features of the
initial book are barely recognizable. It embraces sixteen demonstra-
tions and three hundred fourteen illustrations of the various organs and
structures of the body. For the elemental student, whose knowledge
of anatomy is meagre, this illustrated manual is destined to prove a
boon, and it will undoubtedly gain the circulation it merits.

*By Simon M. Yutzy, M. D., Instructor in Osteology and Demon-
strator of Anatomy in the University of Michigan. P. Blakiston's Son
& Company, Philadelphia.

FORTHCOMING PUBLICATIONS.
Messrs. W. B. Saunders Company announce for publication in
the early fall the following excellent and practical works : "Keen's Sur-
gery— Its Principles and Practice (Volume I) ;" "Sobotta & McMur-
rich's Human Anatomy (Volume III) ;" "Webster's Text- Book of
Gynecology;" "Hill's Histology and Organography;" "McConnell's
Pathology;" "Morrow's Immediate Care of the Injured;" "Stevenson's
Photoscopy (Retinoscopy and Skiascopy);" "Preiswerk & Warren's
Atlas of Dentistry;" "Goepp's State Board Questions and Answers;"
and "Lusk's Elements of Nutrition." The most notable announce-
ment is the new work on "Surgery," edited by Doctor W. W. Keen,
complete in five octavo volumes, and containing over one thousand
five hundred original illustrations. The entire work is written by
the leaders of modern surgery — ^men whose names are insepar-
ably associated with the subjects upon which they have written.
Without question, "Keen's Surgery" will represent the best surgical
practice of today.

A PROFESSIONAL MEDICAL JOURNAL.

Volume xxviil. OCTOBER, 1906. number X.

ORIGINAL ARTICLES.

MEMOIRS.

PREOPERATIVE TREATMENT FOR ABDOMINAL SECTION.
BYRON ROBINSON, B. S., M. D.

FMOraSSOft of GYKBCOLOGT and abdominal SUKGSKY of WOMKN in tub ILLINOIS MBDICAL COLLBGB.

We do well what we do automatically. Truth should be constantly
advocated because the majority constantly advocate error.

The object of preoperative treatment for abdominal section is to
place the patient in a condition, mentally and physically, to resist the
operation — the anesthesia, trauma, infection.

ADVICE AS REGARDS OPERATIONS.
The demonstration of the functional capacity of the visceral tracts
during the preoperative treatment, in addition to the presenting patho-
logic condition requiring operation, indicates what kind of advice is
to be given the patient or his responsible friends. First and foremost,
during the preoperative treatment the surgeon has no legal or moral
right to announce that there is no danger accompanying the operation.
Second, it is not the surgeon's duty to persuade a patient to accept an
operation. The surgeon may announce that he thinks or it is his
opinion that the operation will benefit the patient, or that the operation
is advisable, or that the patient is better off with the operation. It is
deplorable and an immoral blotch on a surgeon's escutcheon to tell a
patient that there is no danger in the operation and that he will die
without it. There is a mental and physical preoperative treatment. A
proper knowledge of the subject and the statistics may allow an explan-
ation of the probability of success or failure. The surgeon knows, in
general, that operations do not kill — it is disease that kills. However^
the lay mind views the operation as a large factor in cause of death.
With the doubtful statement "there is no danger in the operation" some
unforseen fatal accident may circumscribe the surgeon's position to

434 ORIGINAL ARTICLES .

that of a fool, or more particularly that of a deceiver, a liar, employing
his vocation to the advantage of securing patient's money by false
pretense. Explanation of a patient's death subsequent to an operation
will not extricate the surgeon from a dilemma. The surgeon assured
the people there was no danger connected with the operation and that
is all the people wish to know.

Abdominal section is at present a science — not as formerly a hap-
hazard of fortune and misfortune — ^and demands scientific (physio-
logic) preoperative and postoperative treatment. The real battles in
abdominal surgery are fought before and after the operation. Suc-
cessful abdominal surgery demands systematic prec^erative treatment
because the preoperative treatment demonstrates: (a), the power of
the individual patient to resist the operation (anesthesia, trauma,
infection) ; (b), the individual patient unable to resist the operation
where defects were discovered by preoperative treatment, can be placed
on prolonged preparatory treatment to decide the fate; (c), ample
preoperative treatment may aid in discovering the anatomic and physio-
logic defect that would result in immediate death from operation — a
black eye to surgery. The emergency peritonotomy patient — ^the unfor-
tunate, experiencing no preoperative treatment — ^presents an appalling
mortality which stands in such marked contrast to the successful recov-
ery of patients experiencing preoperative treatment that the laity
vividly comprehend.

DIAGNOSIS.

The diagnosis of disease is the rock and base of all treatment —
medical and surgical. Rational therapeutics rests on rational diagnosis.
The surgeon is first a physician with merely acquired technique. The
surgeon must possess knowledge of every visceral tract — ^its anatomy
and especially its physiology. He must be able to estimate the func-
tional capacity — ^power of resistance — ^if systematic success attends his
surgery. Surgical technique is merely mechanical skill executed on the
base of a diagnosis. The localizing of a uterine myoma is a fragment
of the diagnosis only. The preoperative treatment will demonstrate
the diagnosis of the tractus vascularis (clfesification of arterial and
cardiac lesions), of the tractus urinarius (classification of nephritis),
of the tractus pulmonalis (classification of lung lesions). The diag-
nosis not only includes the local pathologic anatomy but also the phys-
iologic capacity of the patient to resist the operation and recover.
The abdominal surgeon should be a master in pathologic physiology
and pathologic anatomy.

PROGNOSIS.

The diagnosis having been established the preoperative treatment
reveals the basis of prognosis. The acutal state of the functional
capacity of each visceral tract gradually becomes demonstrated by dis-
closing its functional capacity, forecasting the probable results of the
operative procedure — ^the prognosis. Systematic preoperative treat-
ment predicts the probabilities of success and the danger elements, the

POSTOPERATIVE TREATMENT. 436

evil omen. Prognosis is based on the conditions which influence the
success or failure of the operation. The preoperative clinical manifes-
tation of each patient should be known to the surgeon in order to avoid
mistakes and regret as well as for the patient's welfare.

ANATOMIC AND PHYSIOLOGIC REST TREATMENT OF PERITON-
ITIS; OR REST AND STARVATION TREATMENT OF
PERITONITIS.

The most successful treatment af peritonitis or peritoneum in pre-
operative abdominal section I shall term the anatomic and physiologic
rest treatment^ rest and starvation treatment. I learned the main views
from Mr. Lawson Tait, while his pupil in 1891, and I have employed
the method more or less in a modified form for fifteen years. The
method of treatment is applicable to all forms of peritonitis ; however,
its most brilliant results is in acute pelvic peritonitis, subsequent to
abortions and acute salpingitis with peritonitis. The anatomic and
physiologic rest treatment in appendicitis is more uncertain because
appendicitis is the most dangerous and treacherous of abdominal dis-
ease. It is dangerous because it kills and it is treacherous because its
capricious course cannot be prognosed. The essential prognostic story
of appendicitis is — has the appendicular perforation occurred in the
area of the enteron (the dangerous, the absorptive, the nonexudative
area of the peritoneum) or has the perforation occurred in the area of
the colon (the nondangerous area of peritonitis — the nonabsorptive,
the exudative area) . The "rest and starvation" treatment of peritoni-
tis, that is, the anatomic and physiologic rest treatment consists of,
(i), anatomic rest, that is, maximum quietude of voluntary muscles.
The patient lies as motionless as possible in bed and does not rise for
defecation and urination; (2), physiologic rest, that is, minimum func-
tion of viscera. Food is prohibited per os. A minimimi quantity of
fluid per os is allowed which will not excite the gastric peristalsis or
emesis and will aid to slake the raging thirst. Ample fluid may be
introduced per rectum to supply the demand of the tractus vascularis
and to slake thirst. The object of minimum visceral function (physio-
logic rest) is to protect the peritoneum from the distribution of sepsis
through intestinal and other active peristalsis. Visceral rest, quietude,
corrals, circumscribes sepsis by imprisonment, sterilization and diges-
tion of bacteria (through peritoneal exudates and the body guard of
leukocytes). The method of treatment of peritonitis by "anatomic and
physiologic rest" was especially advocated by Sir Samuel Wilkes, the
distinguished English physician, in 1865 (living, 1906), continued by
the celebrated American, Alonzo Clark (1807-1887) by the "opium
splint," and established forever in 1888 by one of the greatest surgical
geniuses of his age — ^Lawson Tait (1845-1902). Opium checks vis-
ceral peristalsis by allowing^ minimum organ function and the perito-
neimi ample time to prepare exudative barriers to obstruct and circum-
scribe progressive bacterial invasion. The anatomic and physiologic

436 ORIGINAL ARTICLES.

rest treatment circumscribes the bacterial infection by exudative bar-
riers, localizes it, so that no operation or a local operation may relieve.
In the presentation of preoperative treatment I shall ccmsider analyt-
ically each thoracic and abdominal visceral tract. Though we cannot
treat the visceral tracts as separate mechanisms, for the patient must
be treated as an individual, yet a careful consideration of the functional
capacity of each visceral tract will safeguard both patient and surgeon*
The functional capacity of each visceral tract demonstrates the vital
power of the patient. The analysis of the patient's anatomy and phys-
iology constitutes the diagnosis and the prognosis — ^the probable fate
of the patient — depends on the diagnosis. The visceral tracts will
practically be considered in the order of their physiologic significance.

I.— TRACTUS URINARIUS.
The tractus urinarius plays the major role of influence in abdominal
section not only in immediate mortality but in subsequent nephritis.
At the Mary Thompson Hospital, where I have performed abdominal
sections for the past eleven years, I estimate that over fifty per cent of
fatal nonemergency subjects are due to postoperative nephritis (perhaps
mainly exacerbated nephritis from anesthesia, surgical procedure, infec-
tion). Perhaps the tractus urinarius is as important in abdominal sec-
tion as all other influences combined. During the three days of usual
preoperative treatment the functional capacity of the kidneys— quantity
and quality — will be demonstrated by each day's measurements and
observation. The tractus urinarius is of maximum importance in body
sewerage. Sudden overwhelming with toxic matters, or the excessive
burdens of anesthesia or infection may jeopardize life.

QUANTITY,
First, the daily quantity of urine for three days should be measured.
For a woman of one hundred and fifty pounds, three pints should be
voided. Changes in daily quantity of urine should excite suspicion.
The visceral drainage modifies the quantity and color. Second, the
urinary constituents must be studied daily.

URINARY CONSTITUENTS,
The chief urinary constituents demanding practical study are: (a),
albumin; (b), sugar; (c), casts (granular, hyaline); (d), urea; (e),
various urinary salts (urine for microscopic specimen should be secured
by the catheter, especially from women).

ALBUMIN (ALBUMINURIA).
The presence of albumin in the urine is not an absolute contraindi-
cation in abdominal section. If the albumin be present in considerable
and persistent quantities it is an evil omen and proper to wait a period
and treat the patient. The quantity of albumin is an untrustworthy,
unreliable test to indicate the renal structure 'or functional capacity. It
is the most common morbid urinal constituent. Though it may indicate
merely pathologic physiology of the kidney — not pathologic anatomy —

POSTOPERATIVE TREATMENT. 487

it is an evil omen. In general the clinical significance of albuminuria
is pathologic conditions of the kidney and particularly of an inflamma-
tory or degenerative character.

SUGAR (GLYCOSURIA).
Glycosuria, or the presence of sugar in the urine, of a pronounced
and persistent form is diabetes mellitis and may be viewed as a symp-
tom of grave defects oi the brain, liver and pancreas. It may be tem-
•porary or constitute simply pathologic physiology. A pronounced and
persistent form relatively contraindicates peritonotomy. It is pro-
gressively fatal in adolescence, in middle life less severe and fatal, in
senescence it is amenable to treatment. It can be produced experi-
mentally in animals.

URINARY CASTS (GRANULAR, HYALINE, EPITHELIAL, BLOOD,
PUS, FAT, BACTERIAL).

Granular casts usually consists of metamorphosed epithelium, pus
or blood. The granular cast varies in dimensions, form, color and
character of granule. Clinically the granular cast is, generally, indicative
of grave pathologic conditions of the kidney of a chronic or degen-
erative character. It is true that the granular cast does not announce
the degree of structural change or functional incapacity of the kidney.
However, the conscientious and scientific surgeon dare not disregard
it. I consider the presence of nimierous granular casts such a vital
contraindicating element in renal incapacity that I refuse to perform
the abdominal section. For ten years this has also been the advice to me
by competent pathologists. Also the records of the fatal cases of post-
operative nephritis demonstrate that numerous granular casts were the
main characteristic. Hyaline casts I do not view in general as a vital
phenomena in preoperative peritonotomy.

BILE IN THE URINE.
Practically the bile in the urine should be eliminated previous to
the section. Qinically bile appears in the urine chiefly from obstruc-
tion of the biliary ducts. Icterus is usually present.

BLOOD IN THE URINE (HEMATURIA).

Blood in the urine is a pathologic condition of the tractus urinarius.
Blood may originate from any segment of the tract, the source of which
the cystoscope and ureteral catheter aid to locate. Clinically it signifies
calculus, neoplasm, infection, hemorrhage from renal papillae, inflam-
matory processes — nephritis. An attempt should be made to locate the
source of the blood.

PUS (PYURIA).

Pus may be derived from any segment of the tractus urinarius, the
source of which the cystoscope and ureteral catheter aid to locate. Pus
is the most common of all pathologic urinary sediments. Pus is such an
important pathologic element in the urine that its source should be
discovered if possible before the abdominal section.

438 ORIGINAL ARTICLES.

UREA.
It is important to estimate the urea in preoperative states. The
normal urine contains about two per cent of urea, or about ten grains
per ounce. Less than one-half urea is a contraindicaticm to abdominal
section and the preoperative treatment should be prolonged.

URINARY SALTS,
The presence of excessive quantities of urinary salts is not a contra-
indication to abdominal secticm. The usual three days of preoperative
treatment of visceral drainage will perhaps sufficiently ccwrect — by
increasing the quantity and clarifying the urine. Dilution of the urine
separates and dissolves the salt granules which become so distant
from each other in their mechanical suspension that clarification ensues.
In the preoperative treatment of the tractus urinarius I administer
during the usual three days eight ounces of one-half to one-fourth
normal salt solution every two hours for six times daily. (In paren-
chymatous nephritis — known by the presence of granular casts — sodium
chloride is not administered as it excessively stimulates the renal epithe-
lium). The patient may and should also drink other fluids during the
preparation. This method of visceral drainage treatment tests the renal
functional capacity, increases the quantity, clarities the urine, dissolves
the salts, and increases the attenuation of the mechanical suspension. It
eliminates the waste-laden material, flushes the tubuli uriniferi and
aids the body sewerage. The "visceral drainage" treatment places the
tractus urinarius at a maximum normal function. It is consequently
prepared to withstand, resist anesthesia, trauma of operation and infec-
tion. The urine should be examined every day during the usual three
preoperative days. During the three usual days of preoperative treat-
ment the patient receives the complete "visceral drainage" treatment,
namely, one alkaline and one-thi^d sodium chloride tablet on the
tongue every two hours, followed by eight ounces (a glassful) of fluid
six times daily. The sodium chloride stimulates particularly the
renal epithelium. In preoperative treatment the tractus urinarius and
its contents or products should be considered separately. Since the
tractus urinarius is the most important factor in abdominal section —
since it has the most potent influence of all the visceral tracts — ^its
anatomy, physiology and pathology must be distinctly in the mind of
the operator for every individual case, as well as the physical, chemical,
and microscopic characteristics of the urine.

II.—TRACTUS VASCULARIS AND ITS CONTENTS— BLOOD.

The tractus vascularis not only requires preoperative treatment, but
also its contents — the blood.

TRACTUS VASCULARIS,
The volume of the tractus vascularis should be placed at a normal
maximum by the "visceral drainage" treatment. It requires about four
pints of fluid daily administered at regular intervals to maintain normal

POSTOPERATIVE TREATMENT. 439

maximtmi volume of blood, which, streaming through the vascular
tract, sustains its function, namely, sensation, peristalsis, absorption,
secretion. Normal blood volume is required by the vascular tract in
order that its peristalsis (heart and arterial contraction) may force the
blood into peripheral organs and tissue. The common function of
viscera (sensation, peristalsis, absorption, and secretion) depends on
the presence of the blood — in quantity and quality. The result of the
diminutive blood quantity and consequent diminutive pulse is observed
with facility in diminished quantity of secretion of urine and glandular
secretion in general shares similarly with the renal glands. A certain
degree of blood pressure is required for normal glandular secretion
(urine, perspiration, intestinal secretion) for normal bodily elimina-
tion. A proper preoperative examination of the tractus vascularis may
reveal valuable knowledge — ^atheroma, arteriosclerosis, syphilis, aneur-
ysm, and hence aid operative decisions. Blood pressure is secured by
administering sufficient fluids to distend the tractus vascularis in order
that it will perform its peristalsis contraction vigorously — eight ounces
of one-half to one-fourth normal salt solution every two hours for
eight times daily is generally amply sufficient. The circulation of the
blood is one of the most perfect mechanisms in nature. It may be
remembered also that the circulation in conjunction with respiration
is an automaton ; each is dependent on the other for vital stimulation.
In man the respiratory and circulatory centers are separated. Hence
careful preoperative supervision may enhance the success of periton-
otomy.

THE BLOOD— CONTENTS OF THE TRACTUS VASCULARIS.

Modem surgical science not only requires an ample volume or quan-
tity of blood for appropriate preoperative treatment in abdominal sec-
tion, but also that the quality of the blood shall approximate the normal
as intimately as possible. The quality and quantity of Hemoglobin con-
tained in a patient's blood is a practical test of vital resistance. Patients
with less than fifty per cent of hemoglobin resist the opposing fac-
tors of surgical procedures defectively — anesthesia, trauma, infection
become prominent menacing factors. If the deficient hemoglobin be
accompanied by malignancy (carcinoma, sarcoma, pernicious anemia)
the patient resists operation defectively. I have operated successfully
with hemoglobin of thirty per cent. With hemoglobin less than forty-
five per cent it is the practice of Doctor Lucy Waite and myself in the
Mary Thompson Hospital to place the patient in bed — anatomic rest —
and resort to forced feeding. The patient is given a certain quantity
of wholesome food for the three regular meals (limited), cereals, albu-
men, milk, cream, vegetables. Also midway between meals, as at lo
A. M., 3 p. M., and 9 p. m., the patient receives eggnog (composed of
one raw egg, four ounces of milk, four ounces of cream, one to two
drams of spiritus frumenti) or other nourishing fluid. The method of

440 ORIGINAL ARTICLES.

forced feeding quickly demonstrates the vital capacity of the patient
for improvement. The rule is that under this method the patient gains
one per cent of hemoglobin daily — especially the nonmalignant subjects.
In two to three weeks the patients frequently resume sufficient vitality
to resist the anesthesia, operative trauma, infection. The typical non-
malignant deficient hemoglobin subject is one with periodic hemor-
rhages from uterine myomata, and they are particularly responsive to
increased hemoglobin from forced feeding and anatomic rest (not rising
for urination or defecation). The subject nonresponsive to increase of
hemoglobin from forced feeding and anatomic rest defectively resists
anesthesia, operative trauma, infection. Such subjects are liable to be
suffering from progressively fatal disease — malignancy, pernicious
anemia, leukemia. A precaution should be borne in mind, for example :
I have observed quite a number of patients possessing less than twenty-
five per cent of hemoglobin slowly recover through many months
whereas a major operation would quickly snuff out life. Does the con-
dition of the tractus vascularis — heart and arteries — enable the anes-
thetizer to choose the appropriate anesthetic? It is not the mitral or
aortic insufficiency that alarms the surgeon. It is myocardial subjects,
the patient with fatty degeneration of the heart, the atheromatous or
sclerotic arteries that materially influence the mortality of the abdom-
inal section. The pulse, caused by the variation of pressure within the
artery due to intermittent expulsion of blood from the heart, demon-
strates multiple and useful views during preoperative treatment, fre-
quently deciding in favor of or against an operation.

III.— TRACTUS RESPIRATORIUS.

The regular rhythmical tractus respiratorius is of extreme impor-
tance in preoperative treament for abdominal section, because it is a
vital tract for the maintenance of life. It must resist the brunt of anes-
thesia, hence it must be placed in a maximum normal physiologic con-
dition. The respiratory tract iS significant because it may suffer post-
operative from anesthesia, irritability, bronchitis, pneumonia and
seventy-five per cent of postoperative abdominal section emboli lodge
in the lungs. Percussion, auscultation and observation and the micro-
scope reveal the condition of the respiratory tract. A patient with
advanced pulmonary disease should not be operated upon unless it be
an emergency surgical procedure. Careful inspection of the naso-
pharynx should be practiced in order that all obstacles (adenoids,
polypi) to a successful operation may be removed. Rhinitis may lead
to postoperative pneumonia or other infection. A subject with marked
pulmonary tuberculosis should not be operated. If the tuberculosis
recovers the operation may occur.

Precaution, — Do not operate while the patient is suffering with any
acute respiratory attack as bronchitis, cold, influenza, rhinitis, recent
increased respiration.

POSTOPERATIVE TREATMENT. 441

IV.— TRACTUS INTESTINALIS.

In peritonotomy it is peculiarly advantageous for patient and opera-
tor to institute careful preoperative treatment in the tractus intestinalis
for the purpose of inflicting minimum visceral operative trauma and
smoothe postoperative recovery. The tractus intestinalis is of maxi-
mum significance in bodily sewerage. Preoperative treatment should
be of sufiicient vigor and duration to completely evacuate the tractus
intestinalis of its contents — feces and gas — so that the colon and enteron
may be found at the operation completely collapsed, and especially the
enteron should appear and feel like slippery ribbons.

A collapsed tractus intestinalis, completely evacuated of feces and
gas allows maximum space for intraabdominal observation and manipu-
lation of the pathologic factors with minimum opportunity for visceral
trauma and infection. The tractus intestinalis should be placed at a
normal maximum function during preoperative treatment in order that
it should be collapsed and contracted during the operation, and hence
its blood supply is a minimum. A completely evacuated tractus intes-
tinalis is prepared to resist trauma and infection. The complete pre-
operative evacuation of the tractus intestinalis is the chief prophylaxis
against postoperative pain^ — ^violent colic — (wild peristalsis) and the
distressing meteorism. A tractus intestinalis distended with feces and
gas resists trauma or infection to a limited degree. Unfortunately prac-
tically any manipulation or trauma of the tractus intestinalis desqua-
mates the epithelium and produces thousands of atria for infection,
portals of entrance in the tractus lymphaticus, hence the most safe per-
itonotomy is the one in which minimum manipulation, visceral trauma
and exposure occur — this was a chief factor in Mr. Lawson Tait's phe-
nomenal success. Preoperative treatment of the tractus intestinalis
implies two important factors, namely, (a), evacuation; (b), diet.

EVACUATION.

I employ set days for nonemergency patients. For Tuesday after-
noon operation I begin the preoperative treatment Saturday, and for
Friday afternoon I begin Tuesday. During the usual three days
of preoperative treatment the patient receives the visceral drainage
treatment, namely, immediately before or after meals one alkaline tab-
let (composed of aloes, one-third grain ; cascara sagrada, one-fortieth
grain; sodium carbonate, one grain; potassium carbonate, one-third
grain; magnesium sulphate, two grains) and one-third of a sodium
chloride tablet (containing twelve grains) is placed on the tongue and
followed by eight ounces of water. This is repeated at lo a. m. (middle
of forenoon), 3 p. m. (middle of afternoon), and 9 p. m. (bedtime),
that is, the patient receives one alkaline tablet, one-third sodium chloride
tablet and eight ounces of water (fluid) every two hours, for six times
daily. The method affects the entire enteron and colon, evacuating
masses of mucus, particles of salts, and small hard fecal masses.

For gross evacuation of feces, scybala, three definite remedies are

442 ORIGINAL ARTICLES.

used — ^hydrargyrum chloridum mite (mild chloride) ; magnesiimi
sulphate plus magnesium citrate (granular) ; castor oil ("honey oil").
Castor oil is a valuable cathartic in preoperative and postoperative
treatment because it evacuates the tractus intestinalis with limited colic
or griping, dissolves feces excellently and produces slight exhaustion
on the patient. However, it is generally impractical for use on account
of its nauseous character and the patient's refusal to accept it. Recent
attempts to disguise its objectionable taste have been quite successful,
and I here present a formula from my colleague, Doctor Walter M.
Fitch, of Chicago, that he designates ''honey oil," which I am using
with great satisfaction. The rule I use is to alternate magnesium sul-
phate, one dram, plus magnesitlm citrate, one dram, with four drams
of "honey oil." The magnesium is always administered first. The
words "honey oil" excite agreeable tastes and suggestions to the patient

Formula and Directions for making "Honey Oil." — Merck's sac-
charin, twenty grains; glycerin, one-half ounce. Rub thoroughly in
a mortar. Place one quart of castor oil in a two-quart bottle, adding
the saccharin and glycerin, and also oil of cinnamon, one dram. Place
the bottle in a pan of cold water over gas stove and heat until the oil is
quite warm or hot. Shake thoroughly and allow it to cool. If upon
cooling the glycerin is seen to separate it should be reheated and
shaken.

Seventy-two hours previous to the operation (say Saturday or
Tuesday noon) hydrarg)rrum chloridum mite, grains three, is admin-
istered, and two hours later, one dram magnesium sulphate, plus one
dram of magnesium citrate (granular) is administered. One hour
later four drams of "honey oil," and in another hour one dram of mag-
nesium sulphate, plus one dram of magnesium citrate (granular). The
next morning (say Sunday or Wednesday morning) hydrargyrum
chloridum mite, grains two, is administered, and two hours later one
dram each of magnesium sulphate and magnesium citrate (granular)
is administered, in another hour four drams "honey oil," as is required
to produce thorough bowel movements. If the bowels do not respond
actively to the cathartics, rectal enema (of various kinds — water, soap-
suds, magnesium sulphate, turpentine and water, equal parts of milk
and molasses) are introduced to stimulate, irritate the colon (sigmoid)
to evacuate. A half dozen moderate bowel movements is a rational
requisite for preoperative treatment in abdominal section. Usually five
grains of hydrargyrum chloridum mite, with one-half ounce of magne-
sium sulphate, and one-half ounce of granular magnesium citrate and
eight drams of "honey oil" is amply sufficient for the evacuations of the
tractus intestinalis. In general the cathartics are all administered dur-
ing the first half of the usual three days of preoperative treatment (that
is, thirty-six hours). The subsequent thirty-six hours preceding the
operation the tractus intestinalis becomes gradually evacuated of its
remnants, mucus, debris in mucal folds and sacculations — ^haustra,
insoluble matters, indurated scybala, fragments of enterolith. The

POSTOPERATIVE TREATMENT.

443

three pints of fluid (one- fourth normal salt solution) with the alkaline
tablets (stimulates the epithelium) aid remarkably in cleansing the tract
of debris. It is a favorable symptom to note the yellow bile glistening
in the fluid, watery stool. With proper care in the preoperative treat-
ment the tractus intestinalis secures some fifteen hours of physiologic
rest (before the operation) , that is, the evacuated tractus intestinalis is
in a state of collapse, contraction, quietude with minimum blood supply.
Its nerve supply is at a maximum rest — ^an empty bowel is a quiet one.
The blood supply to be collapsed, contracted quiet intestinalis is at a
minimum. The excessive quantity of fluid in the bowel evacuations
should be deducted from the estimated quantity of urine voided, for,
the tractus intestinalis is temporarily acting vicariously for the tractus
urinarius.

DIET,
The patient should be placed on semiliquid diet the third day and
liquid diet the second day preceding the operation. No food should be
administered per os the day of operation, that is, for six hours preced-
ing the operation. In preoperative treatment the teeth and mouth
demand thorough inspection and cleansing. Not infrequently pyoal-
veolaris and ulceration exist which should be cleansed, disinfected.
The anus should be inspected for discharges, fistula, ulceration, hemor-
rhoids.

Diet List.
Semiliquid Diet.
Milk toast, soft boiled

t%%, custards, liquids,

gruels.

Liquid Diet.
Milk broth (of any kind),
fruit juice, gruels, egg-
nog (without spirits),
cocoa, clear soup, but-
termilk, cream, albumen,
oranges, tea, coffee, lem-
onade.

General Light Diet.
Mutton, rare roast steak,
chicken, oysters, cel-
ery, soft boiled egg,
baked or broiled fish»
simple puddings, tap-
ioca, rice, farina, toast,
bread (twenty-four
hours' old),^ jellies,,
oranges, liquids. No
stimulants unless or-
dered. Give no corn
beef, cabbage, pork or
veal to any patient.

v.— TRACTUS NERVOSUS.
The tractus nervosus demands for preoperative treatment perfect
rest (maximum quietude of voluntary muscles) and physiologic rest
(minimum action of viscera — limited fluid and diet), mental quietude, -
restful sleep — ^nature's soft nurse, and the quiescence of voluntary mus-
cles accumulates a reservoir of force and strength to resist the operation
and aid in recovery. When a subject requires an abdominal section it
is ethical for the operator to present proper courage which conserves
strength and favors recovery. During the three usual preoperative
days the patient should be practically quiet and alone — one or two inti-
mate friends maintaining encouraging prospects. The tractus nervosus
is powerfully influential in the physiology of the body and a most neces-
sary factor in favorable physiology. Unfavorable communications will

444 ORIGINAL ARTICLES.

check the digestion, modify the blushing cheek to marble paleness,
altering circulation. Mental influences modify perspiration, derange
respiration, in fact potentially influence secretion. ITie preoperative
treatment of abdominal section as regards the tractus nervosus should
be conducted with the greatest quietude, wisdom, skillful tact, for the
influence of mind over matter is profoundly potent.

VI.— TRACTUS PERSPIRATORIUS.
Preoperative treatment of the tractus perspiratorius signifies the
preparatory treatment of the skin and its appendages — sweat glands,
hair, nails, sebaceous and genital glands.

THIRD DAY PRECEDING OPERATION.
Seventy-two hours previous to the operation the patient is given a
thorough soap tub-bath to dissolve oily substances. The body surface
is inspected for ulcers, boils, nevi or other abnormal condition. The
finger and toenails are trimmed, antiseptically brushed and cleansed.
The hair of the head, axillary, genital and anal region is scrubbed with
soap and water, bichlorid (one to two thousand). The hair of the head
is arranged for convenience in two braids. Inspect the eyes, ears, nose,
anus for discharges. Disinfect surface abscesses.

SECOND DAY PRECEDING OPERATION.
On the second day preceding the operation the soap tub-bath is
repeated. The abdomen is shaved as well as the genital and anal hair.
Scrub abdomen, pudendum and anal area five minutes with gauze and
green soap ; wash with bichlorid (one to two thousand) three minutes,
followed by alcohol rub. Apply green soap compress to remain (twelve
hours) over night.

DAY OF OPERATION.

Six hours preceding operation (afternoon) scrub abdomen, puden-
dum, anal region with soap, bichlorid and alcohol and apply bichlorid
compress (one to two thousand five hundred) on abdomen, genitals and
anal region. At the operation the field of abdominal incision is finally
scrubbed with soap, bichlorid, alcohol.

VII.— TRACTUS GENITALIS.
The preoperative treatment for the genital tract in abdominal sec-
tion depends on its condition and whether the genitals are to be the
field of surgical procedure. The genitals are not necessary for vital
existence, hence, their management in preoperative treatment differs
from such visceral tracts, vital to existence, as the urinary, vas-
cular, nervous, intestinal, lymphatic, respiratory, perspiratory. The
chief preoperative treatment for the tractus genitalis is: (i), for infec-
tive flammatory states, as salpingitis, pelvic peritonitis, cellulitis, post-
abortive sepsis first and foremost is — (a), anatomic rest (maximum
quietude of voluntary — ^not rising for urination or defecation); (b),
physiologic rest (maximum visceral quietude — starvation). Sufficient

POSTOPERATIVE TREATMENT. 445

physiologic rest is required in order that sepsis may not be distributed
by peristalsis. I have practiced the method of anatomic and physio-
logic rest in acute septic or inflamed genitals for fifteen years and the
results are simply marvelous, not only in saving life immediately but
frequently in avoiding dangerous operations (especially in postabortion
sepsis) ; (2), for hemorrhagic conditions, as uterine myoma, anatomic
rest is the essential preoperative treatment; (3), for neoplasms pre-
operative treatment assumes the usual course; (4), ruptured oviductal
gestation, as a general rule, precludes preoperative treatment and an
immediate operation should be performed. For the general preopera-
tive treatment of the genital tract vaginal douches are employed^
namely, third day preceding operation, ten quarts normal salt solution,.
105° temperature, with fountain s)rringe three feet above head — ^repeated
morning and evening; second day preceding operation, repeat that of

the third day. _ _, ^^ ^„^„ .^r^w

^ DAY OF OPERATION.

Six hours preceding the operation (in afternoon) repeat the vaginal
douche. VIIL— TRACTUS LYMPHATICUS.

The tractus lymphaticus consists of :

(i), VASA LYMPH ATICI, or peripheral anastcwnosing plexuses of
lymph vessels which originate in the meshes of connective tissue. The
lymph channels converging and uniting pass to the lymph glands or
nodes.

(2), GL4NDUL^ LYMPHATICI,lymph glands of nodes which are
structures that receive (afferent vessels) and emit (efferent vessels)
lymph vessels. Man has some five hundred of these lymph glands and
the lymph traverses one or more of these glands previous to termin-
ating in the (subclavian) vein. The lymph gland is a filter for
bacteria, foreign bodies, toxines, et cetera.

(3), TRUNCI LYMPH ATICI, or lymph trunks or large lymph vessels
which conduct the lymph from the lymph glands to the (subclavian)
vein. The lymphatic vessels are solidly and compactly anastomosed,
hence, the lymph may flow in any course, direct or reverse. The
lymphatic tract is the appendage of the tractus vascularis. It begins
and ends in the veins, that is, in the blood vascular tract. The func-
tions of the tractus lymphaticus are sensation, peristalsis, absorption,
secretion. The object of the tractus lymphaticus is universal cell
nourishment and universal cell drainage. Along the borders of the
great lymphatic stream every cell is a harbor for import and export
service. In preoperative treatment it is excellent practice to examine
the lymphatic glands — inguinal, cervical, axillary, epitrochlear, sub-
occipital— ^to observe whether the glands are locally or generally hyper-
trophied; as in tuberculosis, syphilis, infection, leucemia, for it may
modify the operative treatment. Lymph plasma originates from blood
plasma, hence, the two are dependent on each other, and what influ-
ences the tractus vascularis also influences the tractus lymphaticus.
Pathologic physiology in lymphatic glands and channels may suggest

446 ORIGINAL ARTICLES.

a diagnosis by leading the physician to a local lesion in the course of
their route, as enlarging inguinal glands may indicate a genital or
rectal lesion. Modem radical surgery in carcinoma and tuberculosis
depends for its success on a knowledge of the anatomic distribution of
the lymphatic channels and glands.

Enlarging lymph glands herald the advance of disease. The
tractus lymphaticus stands as a sentinel or guard over bodi}}^ nourish-
ment. It filters and checks the deleterious and poisonous substances
from gaining access to the parenchymatous cell. The lymph glands
imprison and sterilize the inert substance and carcinomatous cells
retarding the progress of carcincxna. The detectable route of the most
implacable enemy of man— carcinoma — ^is through the tractus lymphat-
icus. The early detection and successful treatment of the precarcin-
omatous stage must be accomplished by the recognition of pathologic
physiology of the tractus lymphaticus. The tractus lymphaticus pre-
sides as a tissue inspector and protector in the interest of the general
organism, digesting, sterilizing, and imprisoning. In the preoperative
treatment of abdcwninal section it frequently occurs that special serous
sacs (peritoneum, pleura, pericardium) may contain more or less fluid.
If the treatment does not diminish the peritoneal accumulation, para-
centesis abdominis should be performed, gradually extracting some
pints daily. If the three usual preoperative days of anatomic and
physiologic rest allows any considerable lymphatic edema of the
abdominal wall and distal limbs to remain, it is well to prolong the
treatment. The preoperative treatment of the tractus lymphaticus is
essentially visceral drainage. The lymph tract should be depleted of
waste laden material. The usual three days of preoperative, "visceral
drainage," that is, the administration of one-third sodium chloride plus
one alkaline tablet every two hours, followed by eight ounces of fluid
six to eight times daily, is generally amply sufficient to drain, deplete,
eliminate the waste laden, toxic material of the tractus lymphaticus
in order that the patient may resist the abdominal section — ^anesthesia,
trauma and infection.

Chicago, Illinois.

THE UNIVERSITY OF MICHIGAN SUMMER SCHOOL.
DEPARTMENT OF INTERNAL MEDICINE.

DAVID MURRAY COWIE, M. D.,

HCSTHVCTOK.

HUGO ABRAHAM FREUND, M. D.

ASSItTAMT.

The fourth session of the Summer School in the Department of
Internal Medicine was completed August 3, 1906. The course is
designed primarily for postgraduate students, and has been offered dur-
ing the past two years to a limited number for the reason that only by

SUMMER SCHOOL. 447

this plan can individual teaching be given and each student have actual
contact with the various cases as they present themselves to the clinic.

The purpose of the courses given in Internal Medicine has always
been to present, by means of demonstrations, all the modern clinical
laboratory methods which we have found by years of experience to be
indispensable in diagnostic work. Only these, to the exclusion of many
useless and impractical methods, have been considered.

The clinical laboratory is thoroughly equipped, in every detail, for
carrying out such instruction as well as for conducting research work.
Through the untiring efforts of Professor Dock diagnostic instruments
of precision have been well selected, and each year the supply is aug-
mented to include types of all modem advances. Since his incumbency
of the Chair of Internal Medicine and Diseases of Children the clinical
laboratory idea has been inaugurated and developed from a little room
of ten by ten to its present dimensions of four large rooms, including
one set apart for special research purposes. So important an adjunct
has the clinical laboratory become to the various branches of clinical
medicine and surgery that at the present time the University Hospital
has five laboratories representing respectively the clinics of Internal
Medicine, Diseases of the Nervous System, Surgery, Gynecology, and
of Otolaryngology.

The plan upon which the work was based during the last session of
the school was to permit each student to personally conduct, after he
had mastered the technique, the laboratory examinations of the urine,
blood, sputum, stomach contents, stools, and milk. This required daily
attendance, Saturday excepted, from 8 to 1 1 a. m., for six weeks, and
his presence during the afternoon for the purpose of perfecting his
technique.

The course is essentially one of hard work, and we have taken
occasion to advise those who are looking for rest not to attempt it.
The large number of cases that enter the clinic and the fact that the
students are given opportunity, as soon as possible, to assist in the
routine work of the clinic, make this absolutely necessary, as a more
or less definite amount of work must be accomplished each day. In
addition to the laboratory training each student received much time
was spent at the bedside, and in this way the true relation of the
laboratory findings to the data obtained by history and physical exami-
nation were shown. Discussion of cases before the entire section
was indulged in freely and the diagnosis, treatment, and prognosis
considered.

The scope of the clinical examinations of the blood, urine, stomach,
stools, and milk can be better understood by reference to sheets from
the daily record books. These are reproduced here in 'about one-half
their size.

448 ORIGINAL ARTICLES.

UNIVERSITY HOSPITAL

DEPARTMENT OF INTERNAL MEDICINE

BLOOD EXAMINATION

Name Date Hour.

In-patient, No Out-patient, No

Extra Dr Diagnosis

Fresh drop : Flow Color Consistence. . . .

Microscopic : Red cells — Size Shape

Color relative number rolls

Leukocytes, number other characteristics

Plates Fibrin

Parasites

Number of cells, red Method. *

Number of cells, white Method

Hemoglobin Method

Specific Gravity Method

Differential count. No red cells

small lyniphocytes microcytes

large lymphocytes macrocytes

transitional poikilocytes

polynuclear vacuolated

eosinophile polynuclear normoblasts

eosinophile mononuclear megaloblasts

myelocytes undetermined . . .

mast cells

degenerates

Other observations
Remarks

Examined by.

SUMMER SCHOOL. 449

UNIVERSITY HOSPITAL

DEPARTMENT OF INTERNAL MEDICINE

URINE EXAMINATION

Name Date

In-patient, No Out-patient, No

Extra Dr Diagnosis

Sample, hour 24 hours voided catheter.

Quantity Specific Gravity Reaction Color.

Clear Turbid Floaters

Albumin : Heat and nitric acid '.

" Acetic and ferrocyanide

Heller's

Albumose: method

Glucose Fehling quantity

K O H phenylhydracin

fermentation quantity "t

Bile-coloring foam Gmelin

Urobilin Indican

Acetone Diacetic acid

Ferric-chloride reaction Diazo

Sediment, amount color appearance

Microscopic : crystals

red blood cells, No ; condition

leukocytes No ; kind

epithelial cells ; kind

Casts '

cylindroids

Spermatozoa Bacteria

Protozoa . . .
Remarks

Examined by.

450 ORIGINAL ARTICLES

UNIVERSITY HOSPITAL

DEPARTMENT OF INTERNAL MEDICINE

SPUTUM EXAMINATION

Name Date

In-patient, No Out-patient, No

Extra Dr \ Diagnosis

Amount Sample 24 Hours . .

Color Character Consistence

Odor Reaction

Cells : pavement epithelium ^ alveolar cells.

dust cells heart-failure cells

leukocytes, mononuclear

" polynuclear

" eosinophile

colloid myelin bodies

red blood cells

Tubercle bacilli : method used Number

appearance

Other bacteria, number and kind.
Elastic tissue, kind and quantity . . .

Spirals, kind and number

Charcot-Leyden crystals

Other findings

Examined by.

SUMMER SCHOOL.

UNIVERSITY HOSPITAL

451

DEPARTMENT OF INTERNAL MEDICINE

STOMACH EXAMINATION

Date . . .Name in full. . .Test meal employed. . .Time in stomach* . .
General Character. — Quantity c. c Lavage after

odor color bile

blood, macroscopic occult

remains from previous meal

mucus

Microscopic Characters. — Blood corpuscles Leukocytes

fragments of mucosa Specimen No

sarcinae yeasts moulds protozoa

epithelial cells

fragments of mucosa Specimen No

Filtrate quantity color specific gravity •. . .

Reaction. — ^Litmus Congo red

Hydrochloric acid. — Giinzberg !

dimethyl-amido-azo-benzole

Lactic acid. — Uffelmann Kelling

ether extract Method

Acetone. — In distillate, Lieben Gunning

■%

gms Method

. % gms Method

(a) FreeHCl

(b) Loosely combined HCl.

salts

(d) Total acidity

Lactic acid % .

Digestion Tests. — Pepsin, millimeter digested sq. =

P. V. Computed for lo hrs = ,

Pepsinogen, millimeter digested sq =

P. V. Computed for lo hrs =

Chymosin

Chymosinogen

Proteid digestion. — Primary albumoses

Secondary albumoses Peptons

Starch digestion

Starch (dark blue) amylodextrin (lighter blue) . . .

erythrodextrin, violet blue violet red violet red

mahogany brown

achroodextrin, anachrom

Maltose Dextrose

Absorption Test — KI reaction occurred in

Motor Power Test. — Salol reaction occurred in

Remarks

Examined by.

452 ORIGINAL ARTICLES.

UNIVERSITY HOSPITAL

DEPARTMENT OF INTERNAL MEDICINE

STOOL EXAMINATION

Diet

Macroscopic Characters. — Color Odor Reaction.

Form

Blood

Occult. (Note color changes)

Time of reaction

Food Particles

Mucous characters*

Parasites

Microscopic Characters. — Blood Protozoa.

I muscle fibers, )
unaltered starch v
cells, et cetera )

Oil droplets

Fatty acid crystals and soaps

Eggs Parasites

Yeast cells

lodin reaction

Chemical Characters. —

Sublimate test — color

Gas development

Remarks

Examined by.

SUMMER SCHOOL. 453

UNIVERSITY HOSPITAL

DEPARTMENT OF INTERNAL MEDICINE

MILK EXAMINATION

Name Time collected Time examined.

Specific Gravity Reaction

Total Acidity

Percent of Fat in

Number of Bacteria per cubic centimeter

Microscopic Characters

Remarks

Examined by

That the students during the past summer session had ample
opportunity with the abundance as well as variety of clinical material
is evidenced by the following report. The eighty-eight cases included
in the report represented almost every branch of Internal Medicine.
Each of these cases was seen, examined, diagnosticated, and treated
during the session. Not only the simpler cases which permit of ready
diagnosis, but especially many of the more puzzling states, that require
accurate scientific methods of examination, came under observation.

In the report presented the diseases have been classified in the usual
manner, but for convenience of description diseases aifecting the several
systems, such as the circulatory and digestive systems, will be consid-
ered singly.

Of diseases affecting the circulatory system we have included those
of the circulating fluid, the blood ; those of the channels through which
the blood flows, the blood-vessel; and those of the cause of the flow,
the heart. According to this scheme —

♦ ♦ ♦

Anemias first attract our attention. Of the two cases of pernicious
anemia, one in a young woman had remarkable features. She com-
plained, in addition to the many ordinary symptoms, of an uncontrol-
lable desire to sleep at all times. No matter how enlivening the
surroundings, the tendency to fall asleep could not be overcome. This
symptom preceded those for which she sought relief for several years.
On admission to the Hospital she had nineteen per cent hemoglobin and

ORIGINAL ARTICLES.

less than one million red corpuscles — ^many of which were deformed,
a high per cent of small lymphocytes, with but few megaloblasts. In
the gastrointestinal tract the usual accompanying symptoms of achlor-
hydiria, rapid motility, and slight diarrhea, making the characteristic
picture of the so-called achylia gastrica, were present. The improve-
ment in this case was rapid and marked. In four weeks the hemo-
globin had risen to fifty-two per cent and the red corpuscles to two mil-
lion one hundred thousand.

RECORD OF CASES.

Admitted

Actinomycosis

Anemia — Pernicious

Anemia — Secondary

Aneurysm — Aortic

Arteriosclerosis '.

Arthritis — Hypertrophic

Ascites

Asthma — Bronchial

Bronchitis — Acute

Bronchitis — Chronic

Diabetes Mellitus

Enteritis — Acute

Enteritis — (in children)

Emphysema

Gall-stones

Goitre — Cystic

Goitre — Exophthalmic

Goitre — ^Simple

Heart — Malignant Endocarditis

Incompensated

Irregular

Mitral Regurgitation

Neurosis

Hodgkin*s Disease

Intestinal Obstruction

Leukemia — Splenic »

Malnutrition— (infants).-

Meningitis — Acute

Miliary Tuberculosis

Situs Viscerus Transversus

Stomach — Carcinoma

Dilatation

Neurasthenia

Hyj>eracidity

Subacidity

Persistent vomiting...

Gastritis — Chronic mucous...
Chronic simple ...

Ulcer — Duodenal

Syphilis — Hereditary

Trichomoniasis

Tut>ercuIosis — Chronic Pulmonary
Tumor — Pelvic ,

Retroperitoneal ,

Typhoid Fever.. ,

Miscellaneous. ,

Total.,

Rcc'ver'd

or
Im|MX>ved

Unch^d

8 3

Tr'ntfr'd

Died

Not
Treated
orAdvis'd

SUMMER SCHOOL. 455

A case of myelogenous leukemia gave ample opportunity for the
student to acquaint himself with all the cell characters of this disease,
the importance of the early recognition of which cannot be overesti-
mated. The spleen was enormously enlarged and filled in the greater
part of the abdomen. The blood picture on entrance, August 9, 1906,
was as follows:

Flow, free. Color, red. Consistence, fair.
Number of cells, red, 3,504,000. Method, Thoma-Zeiss.
Number of cells, white, 291,200. Method, Thoma-Zeiss..
Hemoglobin 70-80%. Method, Tallqvist.
Differential count No. 526:

small lymphocytes

11.4%

large lymphocytes

transitional

2.8

polynuclear

257

48.8

eosinophile poly.

4.5

eosinophile mono.

1.2

myelocytes

9.8

mast cells

7.6

normoblasts

Just before discharge from the hospital, August 24, 1906, the blood
picture was as follows :

Flow, free. Color, bright red. Consistence, normal.
Number of cells, red, 4,300,000. Method, Thcwna-Zeiss.
Number of cells, white, 9,600. Method, Thoma-Zeiss.
Hemoglobin, 60-70%. Method, Tallqvist.
Differential count. No. 500:

small lymphocytes 6.1%

large lymphocytes

transitional 1.6

polynuclear 76.7

eosinophile poly. 1.2

eosinophile mono. .9

myelocytes * 6.4

mast cells 6.7

normoblasts, 6.
Many atypical and degenerated whites.

None of the large mononclear cells showing karyokinetic figures
were seen. The mastzellen were distinctly increased and were more
numerous than the eosinophilous cells, which, however, were not
markedly increased. The most striking features of the case are the
enormous size of the spleen and the marked decrease in the number of
the white cells after ten weeks' treatment, and the corresponding
marked change in the differential count. There was some appreciable
reduction in the size of the spleen. Treatment consisted of ascending
doses of Fowler's solution and the ^-rays.

456 ORIGINAL ARTICLES.

Two cases of Hodgkin's disease at no time presented any change in
the total leukocyte count, nor in the differential count, except for the
presence of some atypical large lymphocytes with irregularly-formed
nuclei and fine blue staining granules in the protoplasm. To verify
the diagnosis of the character of the glandular involvement the removal
of small glands was employed. One of the cases presented an inter-
esting course of fever of the relapsing type, such as was observed first
by Ebstein and lately seen in a case reported by Ruffin.

♦ ♦ 4c

Blood-vessel Diseases included many cases showing varying
degrees of arteriosclerosis and one case referred from another clinic
gave the section opportunity for examination of symptoms produced
by multiple aneurysms of the left carotid. Blood pressure instruments
were used in the examination of these cases. Practically all forms of
blood pressure apparatus were at the disposal of the students.

♦ 4c ♦

Heart Diseases afforded demonstration of many of the most interr
esting cardiac conditions. One young man of eighteen, who had been
suffering from acute rheumatic fever, developed a malignant endocar-
ditis. He had previously been in hospital for valvular disease. Several
other cases presented for diagnosis and treatment all the cardiac lesions.
Two cases were particularly instructive in furnishing the changes in
the physical sig^s during the emergence from compensation into
incompensation and vice versa.

♦ ♦ ♦

Diseases of the Digestive System always afford material for a
large clinic. The cases as examined in the classified report represent
only a small proportion. In the report only the most pronounced con-
dition the patient suffers from is noted. Should a rendering of the
number of different conditions seen in the eighty-seven cases be given it
would go far beyond the hundred mark, as in the case of pernicious
anemia cited above.

The bulk of stomach conditions can be classed as neuroses, forms
of nervous dyspepsia, of which there are many, secretory, sensory, and
motor. There is seldom a pure secretory, sensory, or motor neurosis,
but usually a combination. It is this class of cases the physician has
most to do with, and it is this class he has the most difficulty with, but
for which he can do the most good.

Carcinoma, which is always with us, favored us with two charac-
teristic cases. There were also borderline cases which served as texts
for study and comparison. The grouping of symptoms, chemical and
microscopic findings, enabled those who gave heed and worked hard
opportunity to differentiate the neuroses from the gastritidis, the gas-
tritidis from malignancy, and ulceration, which doubtless is always
associated with a gastritis and a neurosis of some kind. Oppler-Boas
bacilli, sarcinae, and yeasts were demonstrated.

SUMMER SCHOOL. 467

The case of dilatation served as an example of a type of dilatation
from which other forms of dilatation could be taught. Fran this case
could be shown the great necessity for care in deciding upon what
method of treatment should be carried out. It is not every case of
dilatation that requires the surgeon's knife. Too often a gastroenter-
ostomy is performed without sufficient data; without first subjecting
the case to thorough and prolonged scientific investigation. For the
same reason it may also be said that too often a case of dilatation is
allowed to go too long without recognition and without the surgical
interference which may be so absolutely necessary. It was shown that
perhaps in no other field where the surgeon and the internist come
together is there necessity for such prolonged and accurate observation.
Mistakes are usually made because the physician in general fails to put
himself in possession of accurate knowledge concerning his gastroin-
testinal cases.

One case of duodenal ulcer gave ample opportunity for the consid-
eration of peptic ulcer, and the differential diagnosis was gone into
thoroughly. The value of the occult blood tests in the differential diag-
nosis of cancer and ulcer could be taught by this case and the two just
preceding.

One of the most difficult tasks the gastrologist encounters is to
decide whether a case is truly a gastritis. All forms of organic diseases
of the stomach are simulated by the neuroses. There must of necessity
be associated with every gastritis a neurosis. When bits of stomach
mucosa are found in the washings, in the eye of the stomach tube, or
mixed in with the recovered contents, a fairly good idea can be obtained
of conditions going on at least in portions of the stomach. These bits
of tissue were carefully searched for and their appearance demonstrated.

Among the intestinal diseases in addition to the case of duodenal
ulcer, mucous colitis, trichomoniasis, typhoid fever, and the intestinal
indigestions in children were shown.

Diseases of the Lungs were represented by twelve cases of tuber-
culosis which furnished ample material for the demonstration of the
important physical signs of this disease. Of special value were those
cases presenting the very earliest signs of the disease, physical phe-
nomena with which every practitioner should acquaint himself, for it is
during the incipient stage of tuberculosis that so much can be done
to save life, if proper conditions are brought about. The great
importance of frequent examination was shown and it was impressed
upon each student that it is possible to diagnose tuberculosis of the
lungs before tubercle bacilli appear in the sputum. In the older cases
all the signs of large and small cavity formation could be demon-
strated, as well as the signs and symptoms of the frequent compli-
cations, pleurisy with effusion, and emphysema, which occurred in some

458 ORIGINAL ARTICLES.

of the cases. The importance of the examination of the gastrointestinal
secretions, and excretions in tuberculosis were also considered.

* * *

It is noteworthy that during the course three cases of complete
transposition of the viscera were seen. Two cases of cerebrospinal
meningitis, in which lumbar puncture and cytological examinations of
the recovered fluid were made, were observed from day to day. The
effect of lumbar puncture upon the child's blood pressure was noted.
In one day nine cases of goitre came before the section, five of which
were in one family. The cases as a whole represented all forms of
goitre, including the combination of cystic and exophthalmic in one
case.

DEPARTMENT OF SURGERY,
CYRENUS G. DARLING. M. D.

CUNICAL PKOFBaOR OV SUBGBBT.

The Department of Medicine and Surgery in the University of
Michigan took an advance step five years ago by establishing a Summer
Medical School, the courses of which were designed to ultimately rank
with those given in other departments. The laboratory courses were
successful from the onset but the clinical courses were of slower growth.
The latter were intended for the practicing physician who found time
and need for replenishing his fund of knowledge, but who was some-
what dilatory in discovering a method of teaching in vogue at Ann
Arbor that was not contemplated by the postgraduate schools of larger
cities.

This year four clinical courses — Medicine, Surgery, Gynecology,
and Otolaryngology — were given and well attended. The physician
who came to study newer clinical methods and special lines of prac-
tice, found an extensive variety of clinical material, excellent for
teaching purposes, because it was so placed at his disposal that he could
study the disease and treatment of the individual patient from the time
of entering the hospital until he left. So many disparaging statements
have been made in medical society and daily newspaper by interested
persons that medical men not acquainted with the University hospital
clinics might believe that the facilities for teaching medicine and sur-
gery at the University of Michigan are seriously hampered because of
lack of material. This report is presented for the purpose of placing
before the medical profession a few facts which should refute the
charge of inadequate clinics. No other hospital in this country gives
to its students such an opportunity for studying disease. Patients come
to this clinic because of the careful study made of every case, which
results in benefit alike to patient and student. Obviously the variety of
cases will not be as great for six weeks as for the entire year, and due
allowance should therefore be made for this deficiency, which will
readily be appreciated by comparison with the yearly hospital report.

SUMMER SCHOOL.

469

SURGICAL SERVICE.
Total number of patients treated in the Surgical Clinic during the

Summer School from June 23 to August 3, 130

Total number of patients treated in the Surgical Qinic during the

Summer School 190

Total number of operations performed, 107

Total number of anesthetics, 67

Ether, 58

Chloroform, i

Locsl anesthetics, 8

Total number of urine analyses, 278

Total number of blood examinations, 171

Total number of pathologic specimens examined, 39

Classified as follows :

Tuberculosis,

Angioma,

Tumors, J

Carcinoma,

csarcoma.

Ulcer,

Appendix, 14

Clot, 3

Cyst, 2

Osteomyelitic tissue, . . i

Granulation tissue, 2

Finger, I

Kidney, I

Knee, i

Thorax, i

Breast, i

Face, I

Hand, i

Lip, 2

Rectum, i

Lymphatics, 2

Neck I

Testicle, i

Tibia, I

The blood and urine of every patient assigned to the clinic are
examined previous to treatment or operation, and still further, to guard
against accident these examinations are repeated at least once a week
while the patient remains in the hospital. In many instances doubtful
tissues are being examined in the laboratory during the progress of
the operation and a report is returned in eight or ten minutes after the
tissue has been removed.

460 ORIGINAL ARTICLES

OPERATIONS CLASSIFIED.

Abscesses treated, 19: aspirated and injected, 6; incised, 13.*

Amputations, 4: finger, 2; leg, i ; thigh, i.

Aneurysm, arteriovenous, of the internal carotid, i : ligation of the
internal carotid artery.

Appendectomies, 14.

Breaking adhesions, 3 : hip-joint, i ; prepuce, 2.

Cauterizations, 3: cauterizing bite, i; sinus, i, for opening bowel.

Circumcision, 2.

Cleft palate, i : lowering intermaxillary bone to place.

Cystotomy (suprapubic for stone), i.

Cystoscopic examinations, 2.

Colostomy (inguinal), i.

Dermoid cyst, i : excision.

Dislocation, 3: compound, 2; open fracture of the radius wired;
tibia immobilized with plate and screws; simple fracture of the lower
end of humerus reduced.

Gall-stone, i : cholecystotomy and choledocotomy.

Glass in foot, i : removed.

Goitre cystic, i : removed under local anesthesia.

Hemorrhoids, 4 : removed by excision, ligation, and cautery.

Herniae, 2: femoral, i, operation; inguinal, i, Bassini operation.

Injections, 6: bladder, 4; elbow-joint, i ; knee-joint, i.

Nephrectomy, i, for multiple abscess of the kidney.

Nephrorraphy, i, for movable kidney.

Osteomyelitis, curetment, 3 : femur, i ; rib, I ; ulna, i.

Plastic operation, 2: face, i ; penis (hypospadias), i.

Sinuses treated, 1 1 : carbolized, 3 ; curetted, 4 ; injected, 4.

Sounding for stone, i.

Stricture dilated, 7 : esophagus, i ; urethra, 6.

Tuberculous glands: excision, i.

Tumors excised, 7 : carcinoma, 4 ; cervical glands, 2 ; hand, I ;
rectum, i.

Epithelioma of the lip, i.

Sarcoma, 2: lymphatics, i ; testicle, i.

Ulcer of tongue, i : excision.

Und'escended testicle, i : lowered to scrotum.

Urethrotomy, external, 2.

Varicocele, i : treated by exposing and ligating veins.

There were three deaths during the summer session. The first
occurred in a case of nephrectomy, and resulted from sepsis and shock.
This patient, a young lady, had a large abscess of the right kidney
opened some weeks before but she still continued septic wth a free
discharge of pus from the sinus. Thinking she had gained all that was
possible under existing conditions, I ventured to remove the kidney,
which was found to contain a number of abscesses and very little

SUMMER SCHOOL. 461

kidney structure. The other kidney began work at once in a faithful
manner but the heart failed and she died two days after the operation.

The second case was that of an old man brought to the hospital
with cystitis and retention of urine because of long-standing stricture.
External urethrotomy was done immediately to relieve the long con-
tinued retention and give drainage to a badly infected bladder. The
patient was septic when he entered the hospital. This was not an
operation of choice; it was the only thing to do under the circum-
stances. There was continued temperature, rapid pulse, and loathing
of food. The patient died six days after the operation.

The third case was that of a young man horribly crushed in a rail-
road accident. The journey by wagon and rail to the hospital took
about two hours. He was in the last stages of shock when he arrived
and died half an hour later. The only operation attempted was for
transfusi<»i.

DEPARTMENT OP GYNECOLOGY.
REUBEN PETERSON, M. D.

PKOFBSSOR or OBSTBTRICS AND GTNBCOLOGY.

^ Not infrequently the clinical teacher in the University of Michigan
is asked, "How large is Ann Arbor?" When told that it is a town of
less than twenty thousand inhabitants, the next query is, "What do you
do for clinical material?" These questions are but natural from one
who is unacquainted with the situation. Having given the matter but
small thought, he assumes that the hospital material is drawn largely
from the town in which the University is situated. But when he once
grasps the idea that only a very small proportion of the material comes
from the town, and that the loyal alumni of the medical school, located
not only in Michigan but in three or four surrounding states, refer their
patients to the hospital for treatment, his eyes are opened to the pos-
sibilities of an institution so situated. He is no longer amazed when
informed that there are over two hundred beds in the University Hos-
pital usually filled and patients waiting their turn for admission. His
eyes are opened, unless for reasons of his own, he keeps them tightly
closed and refuses to be convinced. The following report of the work
in the Gynecologic Clinic during the last summer session is not sub-
mitted for those who know the facts, yet still keep up the cry of "no
material." Their cry would be the same if a thousand major opera-
tions were to be performed daily in the hospital.

It has been the writer's good fortune to teach postgraduate students
in various medical schools. He has seen larger clinics, but never a
teaching clinic that could compare with the one at his disposal last sum-
mer, and for that matter during the past four years he has given the
course in gynecology at the University of Michigan. Patients come to
the University Hospital with the understanding that their cases are to

462

ORIGINAL ARTICLES.

be thoroughly investigated not only by the professor in charge but by
the students under him. Hence the eighty patients who entered the
Gynecologic Clinic during the summer session were there for teaching
purposes. Under proper supervision, if his time permitted, the student
could examine and follow every case from the time of entrance to the
hospital until the patient was discharged. He was privileged to see
her not only once, but many times during her stay in the ho^ital. He
was able to verify his diagnoses by what he saw at the operations.
Above all, he could follow the postoperative course of the patient and
judge whether primarily the operation was or was not successful. In
other words the student was able to come in close contact with the
patient. Amphitheatre teaching, with the benches filled with students
who could see and hear but not touch, was conspicuous by its absence.
The following tabulated list of diseases and (^rations speaks for
itself. It was possible to demonstrate all of the commoner gynecologic
affections, not once but many times. There were two operative deaths,
both desperate cases. One resulted from the removal of double pus-
tubes from a weakened, septic patient. The other was a case of chronic
postoperative intestinal obstruction of nearly a year's standing. The
adhesions were released but reformed a week after the operation. Com-
plete occlusion of the intestine followed. The patient and family refused
further operative treatment and death soon ensued.

Summary of Gynecologic Service, University Hospital,
During Summer Session, June 26, to August 3, 1906.

Patients in clinic, ....

operated,

operated twice,

Operations performed.

I per patient per one anesthetic,

4 or more "

Laparotomies,

. 22

General anesthetics for operation, .

. 49

" examination,

Local anesthetic for operation.

Urine examinations,

. 160

Blood examinations, . . . . - • 5^

Diseases Tabulated in Detail.

Ascites, ......•• 3

Cephalhematoma, ....... i

Cervix, anteflexed, ....•••!

cystic.

. 5

SUMMER SCJ1CX)L.

463

endocervicitis,

laceration, bilateral,

laceration, stellate, .

Coccyodynia,

. _ .

Hemorrhoids, internal and external.

Intestinal obstruction.

Kidney, right movable.

left prolapsed,

Ovary, left, absent, congenital.

" absent, postoperative, .

" adherent.

" atrophic.

" cyst of.

" cystic, .

" fibroid of.

right, adherent.

" atrophic.

" cyst of, infected,

" cyst of, not infected,

" cystic.

" prolapsed.

both prolapsed,

Pelvic abscess.

Perineum, complete laceration,

external

internal

Phlebitis,

Recti muscles, separation of.

. 3

Situs invertus viscerum.

Syphilis,

. 4

Fallopian tubes, bilateral pyosalpinx,

• 5

" t.b. c, .

" salpingitis.

left pyosalpinx,

salpingitis.

right pyosalpinx.

Ulcer, varicose, ....

syphilitic, . ...

Urethra, caruncle of, . . .

Uterus, abortion, infected.

. 3

threatened.

absence of, with atresia of vagina and hymer

anteflexed.

carcinoma.

. 3

dysmenorrhea,

. 33

endometritis,

. 48

464

ORIGINAL ARTICLES.

fibroid, submucous,

• • •

. 3

interstitial,

• • •

subperitoneal,

• • •

• 4

menorrhagia.

•

. 5

metritis,

• • •

. i8

metrorrhagia,

• •

premature menopause,

• • •

procidentia.

retroversion, . • .

• • •

. i6

subinvolution,

• • •

pregnancy,

• • •

. 15

fetal death in utero,

• • •

spontaneous deliveries.

• • •

• 9

Vagina, inflammation of , gonorrheal.

• • •

cystocele,

• • •

. 6

rectocele,

• • ■

vesico-vaginal fistula,

• • •

atresia of, . . "

• • •

Vulva, inflammation of, i gonorrheal, i

syphilitic,

relaxed vaginal outlet.

. 8

Arranged According to

Operations.

Appendectomy,

...

Bladder, cystoscopic examination of,

• .

Cervix, cauterization.

...

laceration repaired,

...

polyp removed.

...

removal of,

...

Coccyx, removal of,

Intestinal adhesions, separation of.

. .

Laparotomy,

. . .

. 22

Round ligaments, anterior shortening of i

[Peterson),

Ovary, cyst of left removed.

...

cyst of right removed, .

• . . .

both removed with both tubes.

...

both removed vaginally with tubes.

right removed,

...

, II

right removed with tube.

• •

Perineum, primary repair of laceration.

. • • t

secondary repair of laceration.

secondary repair of complete laceration.

Fallopian tube, right resected

. .

removal of (see under Ovary]

Uterus, dilatation and curettage .

• • •

. 14

hysterectomy.

...

hysterectomy, vaginal

• . ■

myomectomy,

SUMMER SCHOOL. 465

Vagina, anterior colporrhaphy . . . . • i

anterior colpotomy, . . . . .2

posterior colpotomy, . . . . .4

repair of fistula, . . • . • i

DEPARTMENT OF OTOLARYNGOLOGY.
R. BISHOP CANFIELD, M. D.

PROFBSSOR OF OTOLARTHGOLOGY.

The Summer Course in Otolaryngology was given in three divi-
sions :

(a) Examination and diagnosis of the commoner fofms of ear,
nose, and throat conditions with especial reference to treatment. Access
to patients was possible during whatever time was at the student's dis-
posal. Careful hearing tests were made and their importance demon-
strated. All methods of diagnosis and treatment were illustrated and
opportunity given to students to acquire proficiency in them.

(b) Demonstrations of the anatomy of the ear and operative tech-
nique of ear and mastoid operations. This was conducted in the clin-
ical laboratory. All operations were demonstrated and abundant
material provided for practice.

(c) Demonstrations of the anatomy and exercises in diagnosis and
treatment of diseases of the nasal accessory sinuses. The value of
transillumination and the ;r-ray in diagnosis were taught and their
application demonstrated. Operations were performed upon the
cadaver.

The following shows the amount of clinical material used in the
Summer course :

Patients presented,

Conditions presented.

Operations performed,
.Cerumen, . .

Furuncle, ......

Microtia, ......

Polyotia, ......

Microtia with complete atresia of external canal, .

Acute suppurative otitis media.

Acute secretory otitis media,

Chronic catarrhal otitis media.

Sclerosis of middle ear, ....

Chronic secretory media, ....

Chronic suppurative otitis media with cholesteatoma.
Simple chronic suppurative otitis media, .
Effect of suppurative otitis media, .

171

7
4
I
I
I
2
6
8

5
12

4
I
6

466

ORIGINAL ARTICLES.

Tinnitus, . .

Bullet wound of mastoid,

Auditory nerve disease,

Hemorrhage of internal ear,

Sclerosis of the internal ear.

Congenital disease of auditory nerve,

Chronic suppuration of internal ear.

Hypertroirfiy of inferior turbinate.

Edema of inferior turbinate.

Hypertrophy of middle turbinate.

Polyp of middle turbinate.

Spurs of septum.

Deviation and spur,

Deviation and spur with fracture, .

Bleeding septum, . . . .

Perforation of septum,

Nasal polyp, . . . .

Chronic nasal edema,

Postnasal fibroid, . . . .

Fracture of septum.

Gumma of septum,

Chronic empyema of antrum of Highmore,

• 5

Chronic ethmoiditis,

Specific disease of antrum of Highmore, ,

Adenoids, . . . ,

. 3

Tonsils, . . . . ,

. 6

Adenoids and tonsils,

. 28

Chronic irfiaryngitis,

. 3

Secondary syphilis of throat.

• 3

Alveolar abscess,

Tongue-tie,

Hare lip and cleft palate, .

Cleft of soft palate.

Chronic lar3mgitis.

Edema of larynx.

Tuberculosis of larynx,

• 3

Cervical adenitis,

Actinomycosis of cervical gland, .

Submaxillary adenitis.

Goitre, ....

Bronchial cyst,

Asthma, ....

Tubercular cerebro-spinal meningitis,

Pneumococcus cerebro-spinal meningitis,

Epilepsy, . . ' .

Negative,

•

. 8

CLINICAL SOCIETY.

TRANSACTIONS.

467

CLINICAL SOCIETY OP THE UNIVERSITY OP MICHIQAN.

STATED MEETING, OCTOBER 3, 1906.

The President, HUGO A. FREUND, M. D., in the Chair.
Reported by DAVID M. KANE, M. D., Secretary.

REPORT OF CASES.
ANEURYSM OF THE AORTA.

Doctor Frank Smithies : I wish to report a case of aneurysm of
the arch of the aorta, and demonstrate the findings upon the patient.
The case is one which recently came under notice in Professor Dock's
clinic. The present affection is of about one year's standing, the
patient's most troublesome symptoms being sharp, lancinating pains in
the left back, scapular region, aggravated by lying down, and more

Dulness over
pulsating tumor

Liver dulness

FIGURE L
DULNESS OUTLINES ON THORAX — CASE ANEURYSM OF AORTIC ARCH.

severe at night ; feelings of discomfort in the precordiiun ; pains in the
arms, particularly the left ; "dizzy spells ;" dyspnea when lying down ;
irregularity of heart beat ; anorexia.

The examination revealed a noticeable, pulsating prominence in the
thorax, over the left, upper anterior region, centering over the second
intercostal space, parasternal line, extending iftwards to the mid-
sternal line, outwards to just beyond the midclavicular line, upwards,
almost to the clavicle, and below, into the third intercostal space. The
prominence was almost one centimeter higher than the corresponding

468

ORIGINAL ARTICLES.

region on the opposite side of the thorax. The pulsation was heaving,
synchronous with the apex beat, and strongest in the second intercostal
space, left parasternal line. No prominence or pulsation was to be seen
in the back. The palpation revealed no definite tracheal tug. There
was tenderness over the entire tumor are», especially over the second
intercostal space, left midclavicular line, and in the back along the
spine of the left scapula. Over the tumor there was a strong systolic

MM^k

FIGURE II.

pulsation, with slight suggestion of being expansile, followed by a
diastolic shock of moderate intensity. The radial pulses were unequal,
the right being considerably fuller than the left, which was rather diffi-
cult to make out. The percussion is very painful to the patient. An area
of dulness corresponding to the area outlines in Figure I herewith
was obtained. There was no distinct dulness in the back. Auscul-
tation disclosed a systolic, softly blowing bruit at the apex of the heart,
faintly transmitted to the left axilla ; an aortic second sound prolonged
and forcible; the pulmonic second moderately accented. Over the
tumor area there was a loud, systolic bruit, followed by a diastolic

CLINICAL SOCIETY. ' 469

sound of moderate intensity. Auscultation of back, scapular region,
revealed similar findings, but less pronounced. No Drummond's sign.
Lungs were negative. Figure II shows the results of radioscopy. The
fluoroscope disclosed the heart's apex in the fifth intercostal space, midr
clavicular line. An indistinctly pulsating mass was seen to the left of
the sternum in the second and third intercostal spaces, extending out-
ward to the midclavicular line. Blood pressure on entering hospital:
right radial — systolic 139, diastolic 103; left radial — systolic 118,
diastolic 86. Ten days later: right radial — systolic 142, diastolic 115;
left radial — systolic 141, diastolic 112.

The diagnosis of aneurysm of the aorta, with main enlargement at
junction of transverse and descending portions of the arch, with prob-
able diffuse dilation of the entire arch was suggested.

Treatment, consisting of rest in bed, ice-bag, anteriorly, O'C^er the
tumor, with ice-coil to back over painful area, increasing doses of iodid
of potassium, light diet, and regulation of the bowels, has shown an
encouraging improvement in the patient's condition. The tumor mass
has evidently become smaller, the patient's subjective symptoms have
become less marked, the systolic bruit and the diastolic shock are less
distinct, and there has been a relative fall in the diastolic blood-pressure,
although the general pressure is increased. The patient's pharyngeal
mucous membrane shows moderate injection, doubtless due to the
iodid of potassium, of which the dosage has been carried as high as
grams 2.5, thrice daily. The patient's appetite has greatly improved,
and she expresses the wish to return home to take up her daily tasks
on the farm. This is deemed inadvisable at the present stage, and
treatment along the lines already laid down is directed to be continued.

BRONCHIECTASIS,

Doctor Hugo A. Freund : I wish to report a case of bronchiectasis
that has been progressing for some years. The condition was pre-
ceded by an empyema for which the patient had been aspirated in the
Medical Clinic two years ago. At that time there was consolidation of
the lower left side. Not long after a cough developed and since that
time he has been raising a foul-smelling sputum in large quantities.
This has had the characteristics of a bronchiectatic sputum in that it
had the three layers usually met with, and the nauseating carion
odor.

At present the entire left side of the chest, is lower than the right
and does not move on respiration. The breathing over the side,
which is absolutely dull on percussion, is of a bronchial quality below,
and becomes amphoric at the third rib. In connection with this the
clubbing of the fingers, which is marked, is of interest. With the idea
of finding some traces of the early empyema or of reaching one of the
surface pockets of purulent material an exploratory puncture was made
in the ninth interspace, in the posterior axillary line. After penetratii\g
a dense wall for about three-quarters of an inch some clear serum fol-

470 ORIGINAL ARTICLES.

lowed by bloody fluid was withdrawn. The needle was then driven
farther internally, meeting with a leathery resistance. No further
cavities were penetrated.

^ The case presents some further extremely interesting features that
were reported by Doctors Roth and Guide {New York Medical Jour-
nal, October 21, 1905), chief of which are the enormous abdominal
veins. These at first thought would suggest portal obstruction due to
a cirrhosis of the liver, but the patient tells us that they are congenital.
They course from the pubis up to the lower part of the thorax. The
abdomen presents a number of other points worthy of note. It is
enlarged and gives signs of free fluid. The spleen is large and hard
extending down to the level of the umbilicus. The notch is easily felt
on the inner side. The liver, too, extends five fingers below the
margins of the ribs, the edge is round and feels as hard as wood. The
consistency of these organs, the cachectic state of the patient, and the
history suggests amyloid disease. If the kidneys have undergone like
change and the examination of urine can be considered of value in
diagnosis, then surely the low specific gravity, the absence of albumin
and the small quantity of urine argue against amyloid disease. There
is another possibility of the condition being one of cirrhosis of either the
diffuse or the capsular variety. This is extremely possible as pointed
out by Doctor Dock in that we are sure of the increase of fibrous tissue
that has taken place in the thorax and thus might expect like changes
in the abdomen.

DISCUSSION.

Doctor George Dock : I wish to call attention particularly to the
highly developed clubbed fingers. This symptom is an extremely old
one, having been described by Hippocrates, but up to a comparatively
recent time it was supposed to result from pulmonary tuberculosis.
The condition, however, is rarely as marked in pulmonary tuberculosis
and the process a different one. The present case is a typical illustra-
tion of the form described by Marie as pneumonic hypertrophic osteo-
arthropathy. It is especially common in bronchiectasis and empyema.
The patient's statement that it is congenital is quite unlikely and, in
fact, discredited by his mother's statement. In regard to the enlarge-
ment of the spleen and liver, I think this might be due to amyloid
disease, which, from the history of the case, is very likely to exist.
More prolonged examination of the urine might show some such alter-
ation as is found in amyloid disease of the kidney, especially the
increased quantity without lowering of the specific gravity. On the
other hand, I think the enlargement of the liver and spleen might be
due to some other cause, such as obstruction of the circulation of the
lungs, or there might be, in addition, a pericardial adhesion and even
widespread inflammation of the serous membranes. The relations of
the varicose veins have been well described by Doctor Roth, and I only
wish to add that the enlargement here is greater than any I have ever
seen, including some of the reported cases of posttyphoid anastomosis.

CLINICAL SOCIETY. 471

CHRONIC SUPPURATIVE MIDDLE EAR DISEASE.

Doctor R. Bishop Canfield: This patient, a boy, aged fifteen
years, was afflicted with double chronic suppurative middle ear disease
with cholesteatoma of middle ear and mastoid for thirteen years. He
was operated upon several months ago and recently returned to the
hospital for control observation. At the time of operation on the left
ear a true cholesteatoma was discovered with well-defined membrane
occupying the entire mastoid cavity. The growth had uncovered the
facial nerve for a distance of one-eighth inch. The tumor had uncov-
ered the brain upwards and backwards along the course of the superior
petrosal sinus for a considerable distance.

The right ear showed a similar pathologic process. The vestibule
had been penetrated through the posterior semicircular canal so that
the cholesteatoma had reached the internal ear.

The radical mastoid operation with Koerner flap was performed in
both ears. The mastoid cavities were then skin-grafted, and initial
incisions were sutured for primary union.

The patient is presented in order to demonstrate the absence of
deformity, and the fact that the radical mastoid operation can be per-
formed without injury to the hearing. Previous to the operation the
patient had hearing for the conversational voice at a distance of six
inches. At the present time he hears the same voice at a distance of
ten feet.
ANTERIOR SUSPENSION OF THE UTERUS, WITH COMPLICA-
TIONS AND SECONDARY OPERATION,

Doctor Wales M. Signor: I wish to report the case of a woman,
age thirty-seven and married, who was admitted to the Gynecologic
ainic August 28, 1906. Her family and personal history are negative.
Her menstrual history discloses menorrhagia, dysmenorrhea, and
endometritis. Her marital history contemplates seventeen years, during
which time seven children ranging from three and one-half to fifteen
years of age have been born. Labors averaged from thirty-six to
forty-eight hours, and instruments were used in all but the first confine-
ment. Puerperal history negative.

Present affliction began some six or eight weeks prior to admission
to the hospital with sharp pain in the left side, and marked swelling in
the left lower quadrant, which was tender on pressure. Pain increased
by standing or walking, also slightly increased at time of menstruation.
Some headache and fever.

Examination showed the abdomen irregularly distended, more to
the left than to the right, extending well above the lunbilicus, to the
left to the anterior superior spine, to the right a little more than half
way to the anterior superior spine. The fundus of the uterus and
appendages could not be palpated because of the tenderness of region.
Under anesthesia the distension entirely disappeared. No tumor mass
could be felt on deep palpation. The uterus was retroverted. Both
tubes and ovaries were enlarged and prolapsed.

472 EDITORIAL COMMENT.

Operation was performed August 31, 1906. Trachelorrhaphy,
perineorrhaphy, laparotomy. On opening the abdomen the uterus was
found large and retroverted, the left ovary was normal size, there was a
left parovarian cyst the size of an English walnut, and the right ovary
was enlarged and cystic. Both ovaries and tubes were removed, and
the uterus was held forward by an anterior suspension.

On the third day the patient began to complain of severe pain in the
lower abdomen, mostly in the median line. At this time the abdomen
above the umbilicus began to be distended, a condition more marked
a few days later. Up to the time of the second operation the symptoms
consisted of the pain, which was excessive and constant, the tenderness
of the lower abdomen, and the distension of the upper abdominal
region. There was no appreciable elevation of temperature nor dis-
turbance of the pulse rate. The chief complaint was the pain, which
the patient described at different times as "cutting," "tearing," "lanci-
nating," and which could be alleviated somewhat by hot applications,
but controlled only by morphia.

At the time the second operation was determined upon the condition
had changed very little from that at the earliest appearance of these
symptoms, and that only as might be expected from the continued
pain.

The second operation was performed October 2, 1906. The abdo-
men was opened by incision about half an inch to the right of the scar
of former operation. The uterus was found to be held firmly against
the abdominal wall by an adhesion about three centimeters wide. This
was slightly more toward the right comu than the left. The omenttun
was also adherent to the parietal peritoneum at the site of the sus-
pension. The uterus was removed in toto, as well as two gall-stones,
the presence of which had been noted at previous operation.

Since operation the patient has been doing nicely and says that the
"old pain" has disappeared.

EDITORIAL COMMENT.

THE TULASE DISCOVERY FOR TUBERCULOSIS.

Professor von Behring^ who aroused both humorous and serious
comment by declaring before the last International Congress of Tuber-
culosis that he had discovered a remedy for consumption, has placed
the therapeutic innovation — ^tulase — at the disposal of clinicians whose
laboratory facilities are sufficient to insure scientific test.

Tulase is a complex product of tubercle bacilli which have been
subjected to treatment with chloral. It is of the consistency of honey,
and is clear and colorless. Immunity may be conferred in several ways,
the most important being by stomachic ingestion and subcutaneous
injection. For preventive treatment in infants, the administration of

ABSINTHISM IN COMPARISON WITH ALCOHOLISM. 473

tulase in milk by stomach is recommended. In adults who have
contracted tuberculosis the product is injected subcutaneously. For
enteric administration the dose is o.oi centigram, and this is doubled
each day for four days, after which a period of rest for two to four
weeks is prescribed. Very minute quantity is dispensed for hypo-
dermic injection, the amount being doubled every ten days. Then
follows a period of rest for ten days. The maximal dose — one centi-
gram— is employed after a gradual diminution of the period of
treatment and lengthening of the period of rest.

While the product will be distributed free to thoroughly equipped
laboratories and the clinicians thereof, it will be given only under the
following conditions:

(i) Registration of observations according to the Marburg
scheme of temperature curve, et cetera.

(2) Application of the remedy according to instructions agreed
upon in writing, either by the stomach or subcutaneously, or periodic-
ally or continuously.

(3) Dosage, especially in the choice of the first dose and the
gradual increase to the final dose.

(4) The choice of patients in relation to age, health, hereditary
and other conditions which would have an influence on the prognosis,
as to life and physical conditions and the possibility of future obser-
vations.

(5) Regular reports to the Marburg Institute each month whether
the treatment has ceased or is in active operation.

ANNOTATIONS.

ABSINTHISM IN COMPARISON WITH ALCOHOLISM.

Walker has made some interesting observations on the effects of
absinthe drinking. Absinthe is consumed quite freely by the French, and
the ever increasing list of insanities in the Continental republic is prob-
ably attributable in measure to this cause. In contradistinction to alco-
holism, absinthism produces no muscular tremors, while atrophy of the
intellect, stupor, hallucinations, terrible dreams, nausea, depreciation of
appetite, delirium and mania are common symptoms. Deterioration of
the power of concentration, loss of will power and utter indifference to
the welfare of dependents are also factors in the physical and moral
decay. Delirium tremens is superseded by epileptic fits, which, how-
ever, cease to occur upon discontinuance of the absinthe habit. The
insidiousness of the drink is apparent from the fact that the above
symptoms are experienced without any decline of the muscular system,
the decadence of mentality in most cases rendering the victim incap-
able of reform and subjecting him to mental derangement and paralysis,
with ultimate death.

474 EDITORIAL COMMENT.

CANINE DISEASE CONSEQUENTIAL TO COITUS.

Beebe and Ewing report the existence of a venereal disease peculiar
to dogs. ' The principal means of transmission is through coitus, and
the disorder asserts itself in nodular tumors on the genitals, multiple
secondary growths of the skin, metastases of inguinal and abdc»ninal
lymph nodes, together with cachexia. The disease is often accompanied
with fatal outcome. It has been classed as an infectious, malignant
lymphosarcoma. Microscopally the tumors simulate round-celled sar-
comata. No organism has yet been observed, and hence grounds for
assuming that the disease is of parasitic origin are untenable. The
investigators have succeeded in transplanting the disease in normal ani-
mals by means of rubbing scarified mucosa with the tumor cells and also
by implantations.

GONORRHEA OF THE FEMALE GENITALIA.

BouKOYEMSKi recommends the employment of methylene blue in
the treatment of gonorrhea in the female. In a series of experi-
ments the investigator proved the efficacy of the analine product as a
gonocide, it being doubly effective because of its penetrating powers.
The treatment consists of washings of the external genitals and vagina
with a stream of one to two thousandth formaldehyde solution, after
which a saturated solution of methylene blue, four and forty-five hun-
dredths per cent, is applied to the urethra, vagina and cervix. Adminis-
tration of these agents is resorted to once daily or, in less virulent cases,
thrice weekly.

TUBERCLE BACILLI IN PHTHISIC BLOOD.

LuEDKE has succeeded in demonstrating the presence of tubercle
bacilli in the blood of persons affected with pulmonary phthisis. While
the organisms have frequently been found in the blood of individuals
suffering from miliary tuberculosis, this is the first demonstration of
the bacillus in the blood of phthisic patients. Several cubic centimeters
of venous fluid were extracted by means of a syringe and injected into
the peritoneal cavity of guinea pigs, with the result that four of the
animals developed tuberculosis.

THE BENIGNITY OF DESSICATED TUBERCLE BACILLI.

Cadeac asserts that the dust of dried tuberculous sputum is abso-
lutely harmless both to the respiratory and digestive passages. In a
series of experiments on animals he was unable to produce infection in
a single case, either by inhalation or ingestion of the dessicated product.
The reason that the mass of the people is not subject to some form of
tuberculosis, considering the prevalence of infected dust, is explainable
in the fact that the virulence of the organism is attenuated by dessi-
cation.

MINOR INTELLIGENCE. 475

MEDICAL NEWS.

DEDICATORY CEREMONIES AT HARVARD COLLEGE.
The magnificent new medical buildings of Harvard University were
dedicated on September 25-26, 1906. The principal addresses were
delivered by the President of the corporation and by Doctor William
H. Welch, of Baltimore. Doctor Reuben Peterson, of Ann Arbor,
attended the exercises as a delegate from the University of Michigan.
The buildings were erected at a cost of $5,000,000, this amount being
donated for the purpose by Rockefeller, Morgan, and other philan-
thropists. Among the foreigners who received the honorary degree
of doctor of laws on this occasion were Doctors Jose Eames, professor
of pathology and chief of the clinical staff in the Medical School of
Mexico; Franz Keibel, professor of anatomy in the University of
Freiburg; Charles Scott Sherrington, professor at the University of
London ; Francis John Shepherd, professor of anatomy in McGill
University, and Sir Thomas Barlow, professor of clinical medicine in
the University College Hospital, London.

THE PASSING OF A PIONEER DETROIT PHYSICIAN.
Doctor Morse Stewart, of 440 Jefferson avenue, Detroit, died at
his residence October 9, 1906, at the advanced age of eighty-eight
years, having been born in Penn Yan, New Yoric, July 5, 1818.
Deceased received his academic education at Hamilton College and
later studied medicine at the College of Physicians and Surgeons, in
Western New York, and at Geneva Medical College, receiving the
degree of Doctor of Medicine at the latter institution in 1840. Shortly
afterward he located in Detroit and engaged in practice with Doctor
Zina Pitcher. In 1852 his marriage with Isabella Graham Duffield,
daughter of the late Reverend George Duffield, D. D., was contracted.
Six children resulted from this union, five of whom are living, two
being physicians — Doctor Morse Stewart, Junior, and Doctor G.
Duffield Stewart. Mrs. Stewart died in 1888. The Doctor was a
resident of Detroit sixty-six years, during which time he witnessed the
growth of the city from about ten thousand inhabitants to its present
metropolitan number.

MINOR INTELLIGENCE.

The entire department of "Original Abstracts," together with other
important matter, has been crowded out of this issue.

The Ministry of Public Education in Russia has decided that hence-
forth women may qualify for diplomas in dentistry and pharmacy.

The Swedish Medical Society has appointed a committee for the
scientific investigation of cancer. The chairman is Professor Berg.

476 MEDICAL NEWS.

Doctor Robert M. O'Reilly, after four years of faithful service as
Surgeon-General of the Army, has been reappointed by President
Roosevelt.

Kattowitz, Prussian Silesia, is experiencing an epidemic of
ptomain poisoning resultant frcwn the consumption of spoiled meat.
Thirty persons have thus far become mentally deranged.

To impure milk is attributed the recent outbreak of typhoid fever
at Trenton, New Jersey, and it is reported that the State Board of
Health will prosecute several proprietors of unclean dairies.

The consolidation of the medical department of Tulane University
and the New Orleans Polyclinic has been effected, the object being to
make the Polyclinic the postgraduate school of the University.

For obstructing the progress of a Roosevelt Hospital ambulance in
New York City, by driving in front of it and ignoring the driver's
signals, two negroes were recently arrested and subjected to fine.

Stoughton, Massachusetts, is to have a new sanatorium for the
treatment of tuberculosis. A site has already been selected and it is
purposed to erect a building costing one hundred thousand dollars.

Doctor Robert Patterson, of Philadelphia, has been appointed
subdean of the Jefferson Medical College. Doctor Patterson was
formerly chief resident physician of the Philadelphia General Hospital.

Medical men of socialistic tendencies, located on the east side of
New York City, have organized an association, the prime object of
which will be the nomination of socialistic candidates for public office.

San Jose, California, is to have a new county hospital. The
buildings will be located on the site of the old county building destroyed
by the earthquake, and will cost approximately sixty-five thousand
dollars.

In June, 1908, the three hundredth anniversary of the founding of
Quebec by Champlain will be celebrated, and incidentally the French-
speaking physicians of North America will hold their Fourth Annual
Congress.

The Oil City (Pennsylvania) Medical Society will direct the
destiny of the new hospital which is shortly to be established at that .
place. The new institution will be equipped with the latest medical
armamentaria.

Pittsburg is experiencing another epidemic of typhoid fever.
Because of the wretched quality of drinking water dispensed in that
city typhoid is constantly in evidence, but the present outbreak has
assumed unusual proportions.

The Association of Military Surgeons of the United States con-
vened in annual meeting at Buffalo, New York, on September 11, 1906.
An interesting program was presented and participated in by both
American and foreign representatives.

MINOR INTELLIGENCE. 477

The International Congress of Dental Surgeons met in Geneva
during the early part of August. Resolutions were passed urging the
adoption of equal standards by all countries, and an investigation of
the value of diplomas of the various schools of dentistry.

Doctor Willis S. Anderson, of Detroit, editor of the department
of "Laryngology" in this journal, and a member of the teaching force
of the Detroit College of Medicine, has recently been elevated to the
Clinical Professorship of Laryngology in that institution.

At the quarter centenary celebration at Aberdeen University in
September last, the honorary degree of doctor of laws was conferred
upon Doctors J. William White, of Philadelphia, Archibald B.
McCallum, of Toronto, and Howard A. Kelly, of Baltimore.

The coc?iin habit is becoming so widespread in India that it is
menacing the future welfare of the country. The English have adopted
stringent measures in dealing with offenders, and any individual,
detected with the drug on his person is subject to punishment.

Disregard for the ordinance compelling physiciahs to report cases
of childbirth in Birmingham, Alabama, is apparent. Twenty-four
offenders were recently arrested and fined in that city, and admonished
that future violation of the ordinance would entail heavier penalty.

Professor Neisser, Doctor Siegel, and Doctor Lasser, have been
awarded the Simon prize of $25,000 for their contributions to our
knowledge regarding syphilis. Of this amount the first named investi-
gator receives $19,000, and the balance is divided between the other
two.

The Wentworth Hospital Company is to erect a fifty-thousand-
dollar structure in Sacramento, California, articles of incorporation
having already been filed. The stock is to be disposed of in shares of
one hundred dollars each. Work on the building will shortly be
commenced.

The Wayne County Medical Society met in annual session at
Detroit on Monday, September 17, 1906. The following officers were
elected for the ensuing year: President, Doctor J. Henry Carstens;
vicepresident. Doctor William F. Metcalf ; secretary-treasurer. Doctor
Walter Ford.

Through the benevolence of a Delaware philanthropist the Anti-
tuberculosis Society of that state now owns several acres of land near
Newcastle, and will shortly establish a tent colony thereon. As soon
as a sufficient sum is acquired buildings, including a tuberculosis
dispensary, will be constructed.

The prevalence of malaria in Italy is slowly being dissipated by the
government. Formerly the annual death rate from tiie disease was
over fifteen thousand, but since the state has inaugurated distribution,
stations where quinine may be obtained gratis, the annual mortality
has fallen to less than eight thousand.

478 MEDICAL NEWS.

Leicester^ England, has inaugurated a novelty in the form of
public first aid cabinets, which are to be placed on the street comers.
The cabinets ccmtain dressing materials and appliances of use in emer-
gency cases. They are constructed on the plan of our fire alarm
boxes, access being gained by breaking the glass door.

Doctor James E. Pilcher, of the army, and editor of the Journal
of the Association of Military Surgeons of the United States, has been
awarded the Enno Sandter gold medal for his prize contribution on
"The Training of the Medical Officer of the State Forces to Best
Qualify Him for Local Service and for Mobilization With National
Troops."

Owing to the elevation of the entrance standard the medical depart-
ment of Columbia University has suffered a decided decrease in attend-
ance. During the first ten days of registration three hundred thirty-
one students matriculated, while during the corresponding period of
last year four hundred five students were roistered. A decrease has
likewise been experienced by the College* of Pharmacy.

The King Edward Sanatorium for Consumption, located at Mid-
hurst, Sussex, England, has just been completed at an approximate cost
of $i,o<3o,ooo. The institution is ideally situated on a plot of one hun-
dred fifty acres, six hundred feet above sea level, and twelve miles
inland. Accommodation for one hundred patients, each of whose sleep-
ing rooms affords one thousand seven hundred thirty cubic feet of air,
is provided for.

The Clinical Society of the University of Michigan held its first
fall meeting in the University Hospital, October 3, 1906. The cases
reported on this occasion are published in another department of this
number. The following officers were elected for the ensuing year:
President, Doctor Hugo A. Freund; vicepresident. Doctor Leroy W.
Childs; secretary. Doctor David M. Kane. The society will convene
monthly during the college year.

The annual meeting of the Western Surgical and Gynecological
Association was held at Salt Lake City, Utah, on September 3, 1906.
The officers for the ensuing year are : President, Doctor Charles W.
Oviatt, of Oshkosh, Wisconsin ; first vicepresident. Doctor Samuel C.
Baldwin, of Salt Lake City; second vicepresident. Doctor Jabez N.
Jackson, of Kansas City ; secretary-treasurer. Doctor Arthur Mann, of
Minneapolis. Saint Louis was chosen for the next place of meeting.

A measure providing for the medical examination of persons
suffering from communicable diseases has been introduced into the city
council of Saint Louis, Missouri. The scheme carries an appropriation
of forty thousand dollars to defray expenses. Should an ordinance
result new officers will be created as follows: One chief medical
inspector — salary $1,800; one supervisior of nurse inspectors — ^salary
$1,500; assistant medical inspectors — salary $1,200 each; and assistant
nurses — salary $900 each.

INTERNATIONAL CLINICS. 479

RECENT LITERATURE-

REVIEWS.

THE PROPHYLAXIS AND TREATMENT OF INTERNAL

DISEASES.*

There is at present a lively interest in all the problems of thera-
peutics. Many of the old methods are being discarded for better ones.
The reign of therapeutic nihilism has given place to a serious effort to
learn the best methods of treating disease by prevention, by specific
measures and by the proper relief of symptoms. In this desirable
movement the present work is sure to take a prominent part. It is com-
plete, well classified, and the various items are easy to find. The point
of view is a broad one, the development of modem medicine being
thoroughly understood by the writer. The details are such as are
used by the most careful therapeutists at the present time. In case of
difference of opinion, the author's choice is, as a rule, sound, and in
the case of almost every disease he shows personal mastery of all the
necessary manipulations. Prescriptions are sparingly used in the text.
A selection at the end of the volume follows modem lines as far as
possible. The shotgun and polypharmaceutic mixtures still retained in
many text-books are conspicuous by their absence. The metric system
is given the preference, and we are glad to see that in the dosage the
fractions used by many authors, but impossible to follow in actual prac-
tice, are avoided. There are a few survivals, as in giving a dose of
quinin at thirty-seven and one-half grains, or of calomel for fumiga-
tion at seven and one-half grains. Mistakes are very few ; the spelling
for Doctor Lazear's first name as Jose is, therefore, all the more strik-
ing. The volume is of convenient size, clearly printed on paper of
pleasing surface. It can be highly recommended to the classes for
whom it is prepared and is sure to have a favorable reception, and to
still further enhance the reputation of the author. g. d.

♦Designed for the Use of Practitioners and of Advanced Students
in Medicine. By F. Forchheimer, M. D., Professor of Theory and
Practice of Medicine and Clinical Medicine in the Medical College of
Ohio, et cetera. New York and London: D. Appleton & Company,
1906.

INTERNATIONAL CLINICS.*

Volumes II and III of the sixteenth series of this well-known work
have been received. It is only necessary to say that the wise selection
of articles has been kept up with the same skill as before. Both vol-
umes contain valuable practical articles, and give just the sort of infor-
mation that the busy practitioner, no less than the leisurely student.

480 RECENT LITERATURE.

can profitably read. It is impossible to give in a review a proper idea
of the contents. They should be read by every physician. a d.

♦A Quarterly of Illustrated Clinical Lectures and Especially Pre-
pared Original Articles. Edited by A. O. J. Kelly, A. M., M. D.
Philadelphia and London : J. B. Lippincott Company, 1906.

ABDOMINAL OPERATIONS.*

In this work are considered those abdominal operations common
to the two sexes. Section I treats of the subject in general. Section
II treats of operations upon the stomach. Section III of operations
upon the intestines. Section IV of operations upon the liver. Section
V of diseases of the pancreas and spleen. The work shows a wealth ol
knowledge of modem surgical technic bom not only of books but of
large experience on the part of the author himself. The many ref-
erences indicate the former and the clear and detailed descriptions the
latter. The illustrations are numerous, new, and of a high order.
The entire work is a great credit to both author and publishers and
should occupy a prominent place in the library of every abdominal
surgeon. f. b. w.

*By B. G. A. Moynihan, M. S. (London), F. R. S. C, Senior
Assistant Surgeon to Leed's General Infirmary, England. Octavo of
695 pages, with 250 original illustrations. Philadelphia and London :
W. B. Saunders Company, 1905. Cloth, $7.00 net.

A TREATISE ON SURGERY.*

As we review this work and ask ourselves its purpose and place, we
are forced to admit it has both. Not every medical publication has a
distinctive purpose. This one is a treatise, as its title indicates, and
combines in two volumes the essentials of both the science and art of
modern surgery. It has a place because it supersedes and replaces the
out-of-date rehashed books of even a few years ago. Volume I now
before us first takes up inflammation, then injuries and diseases of
special tissues, gunshot injuries, acute wound diseases, chronic affec-
tions, tumors, and other general considerations. Regional surgery of
the head, neck, and thorax complete this part of the work. The illus-
trations are new, the type is readable, and in eveiy respect the book is
attractive to the medical reader. f. b. w.

♦By George R. Fowler, M. D., Examiner in Surgery, Board of
Medical Examiners of the Regents of the University of the State of
New York ; Emeritus Professor of Surgery in the New York Polyclinic,
et cetera. Two imperial octavos of 725 pages each, with 888 text illus-
trations and 4 colored plates, all original. Philadelphia and London.
W. B. Saunders Company, 1906. Per set: Qoth, $15.00 net; half
morocco, $17.00 net.

% ilFician a# Svx^m

A PROFESSIONAL MEDICAL JOURNAL.

VOLUMB XXVIII. NOVEMBER, 1906. NUMBER XI.

ORIGINAL ARTICLES.

MEMOIRS.

MEDICAL ETHICS AND ETIQUETTE.*
GEORGE DOCK, Sc. D., M. D., Ann Arbor, Michigan.

PRQFVSSOR OP MBDICXNB IN TUB UMIVBKSITT OF MICHIGAN.

There is a large number of reformers going about the country
longing to give medical students more work. Some think that what the
young doctor needs is a course of lectures on ethics ; another set think
they need more lectures on practical therapeutics; others lectures on
medical history, and so on. If all the propositions should go into effect
the term of study would have to be nearer forty years than four, and it
might be a good thing if they were carried out, but just at present it
cannot be. It would be very presumptuous in me to give the idea that I
can tell in a few minutes what many people would devote a series of lec-
tures to ; and I intend merely to give my opinion on certain subjects that
I am often asked about and have my attention called to in other ways.
While I may seem to be somewhat dogmatic, that comes from the neces-
sity of speaking rapidly. Nobody nee'd take my word on these things
any more than on the character of a thrill or an albumin reaction or any
other fact. I believe that a man ought to be his own master in all "such
things and not take anybody's dictum without the best reasons. What
I am about to say are simply things that I have noticed in my own
experience and that of others and regard as well worth thinking about,
but I decline to appear as a lecturizer or an oracle.

There are two camps, the one believing that medical etliics should
be gathered into a formal volume and subscribed to as the children of
Israel covenanted at Sinai. The other would have every man his own
judge of right and wrong. The latter view is more pleasing to per-
sons of independent and enthusiastic mind, but not essentially safe. It

*An informal lecture to the Graduating Class of the Medical Department of the
University of Michigan, April 24, 1906.

482 ORIGINAL ARTICLES.

might seem that the rules of conduct that guide gentlemen, and I sup-
pose I should say ladies, in the ordinary walks of life ought to suflSce in
medicine. Or at the most, the rules of gentlemanly conduct plus the
Golden Rule ought to be enough to keep everyone from going wrong.
But in every calling there are certain peculiar obligations that make it
necessary to have a distinct code.. The soldier has his code which would
by no means be proper for men of peace ; the carpenter, his; the black-
smith, his ; and others, theirs. There are certain things that come up in
the carrying out of any kind of a calling that require certain modifica-
tions of general rules. These rules in the case of medicine have, for a
long time, engaged the minds of great physicians and many of them
h^ve devoted a great deal of time to writing out what they thought
right or wrong in medical life. In facf the very earliest scientific med-
ical writer that we know handed down a set of rules that still excite the
admiration of all — Hippocrates, in the Hippocratic oath. He put it in
the form that we now have it, and it is interesting to think that for
2,300 years doctors have paid more or less attention to it and
have tried to follow its teachings. A great philosopher has called it a
monument of civilization of the highest rank. It would be a matter of
interest to find out how many here have ever read the Hippocratic oath.
[Hands raised.] The number is encouraging. In a good many medical
schools when they hand out the diplomas they read the oath and the
members of the class subscribe to it. In other cases copies of it are
handed around. I have here a translation of it that I thought might be
interesting to read at this time. It begins with an invocation to some of
the deities. Some would consider this somewhat silly now, but we have
to put ourselves in the position of the people to whcmi Apollo, Aescu-
lapius and Hygeia were still real and potent.

"I swear by Apollo, the physician, and Aesculapius, and Hygeia and
Panacea, and all the gods and goddesses, that, according to my ability
and judgment, I will keep this Oath and this stipulation ; to reckon him
who taught me this Art equally dear to me as my parents ; to share my
substance with him, and relieve his necessities if required ; to look upon
his offspring in the same footing as my own brothers, and to teach them
this art, if they shall wish to learn it, without fee or stipulation ; and
that by precept, lecture, and every other mode of instruction, I will
impart a knowledge of the Art to my own sons, and those of my teach-
ers, and to disciples bound by a stipulation and oath according to the
law of medicine, but to none others.*' [It is to be remembered that all
this comes down from a time when the calling of medicine was limited,
and we must not consider this a matter for ridicule but one that throws
an interesting light on the origin of the medical profession.] "I will
follow that system of regimen which, according to my ability and judg-
ment, I consider for the benefit of my patients, and abstain from what-
ever is deleterious and mischievous. I will give no deadly medicine to
any one if asked, nor suggest any such counsel ; and in like manner I

MEDICAL ETHICS AND ETIQUEITE. 483

will not give to a woman a pessary to produce abortion." [The admo-
nition about not giving lethal medicines is the earliest indication of what
we look on now as the essential in the art of medicine, that is, not to
destroy life but to save it.] "With purity and with holiness I will pass
my life and practise my Art. I will not cut persons labouring under the
stone, but will leave this to be done by men who are practitioners of this
work." [There are two theories about this: One is that it was con-
sidered improper for the physician to act as a surgeon; but there is
another idea, that they would not remove testes, because in those days
eunuchs were made for commercial purposes ; the Greeks abhorred this,
and the physicians may have thought ii beneath their dignity to aid in
the formation of such imperfect beings.] "Into whatever houses I
enter I will go into them for the benefit of the sick, and will abstain
from every voluntary act of mischief and corruption ; and, further, from
the seduction of females or males, of freemen and slaves. Whatever, in
connection with my professional practice, or not in connection with it, I
see or hear^ in the life of men, which ought not to be spdcen of abroad,
I will not divulge, as reckoning that all sudh should be kept secret.
W^hile I continue to keep this Oath unviolated, may it be granted to me
to enjoy life and the practice of the art, respected by all men, in all
times ! But should I trespass and violate this Oath, may the reverse be
my lot r

I might add that the Hippocratic writings form a very interesting
body of works, and anyone beginning to collect a medical library will
do well to look out for a copy, or a good translation of it. A good edi-
tion was published by the Sydenham Society, and you can occasionally
get the two volumes from twenty-five cents to one dollar a volume, and
you can hardly spend two dollars better than for such books. Occasion-
ally you can pick up translations in French and German, but Adams'
translation in the Sydenham Society series is one of the best. Among
others who have written on this subject, I would suggest Benjamin
Rush, because he was not only a great physician but one of the greatest
men of this country, — signer of the Declaration, fighter during the Rev-
olution, and influential teacher. If he had anything to say it was worth
listening to, and his remarks on the "Medical Life," which you can read
in the university library, are extremely interesting. There is another
set of rules by StoU, a translation of which I had published a couple of
years ago in C^t JteBitiHn anb Snrgeon, ( 1904) . They were originally
published about the same time as Rusfi's, each without knowing of the
other, but having striking resemblances and some differences. StoU's
came from the most aristocratic of the despotisms of Europe and he con-
sidered his a most aristocratic profession ; the other, from a democratic
country and by a man who thought he was as good as anybody else, but
perhaps no better. There are many books on the subject that can be
read with interest. For example, one by Doctor Cathell, of Baltimore,
entitled "The Physician Himself," which has a great deal of worldly

484 ORIGINAL ARTICLES.

wisdom in it, some admirable, all interesting. Another is by Doctor
Mathews, of Louisville. In both France and Germany, where medical
ethics, sometimes called medical deontology, is the subject of formal
teaching, some large bodes have been published. One of the best is a
German work by Albert Moll. Of course you should all read the orig-
inal and the revised Code of Ethics of the American Medical Associa-
tion, and, if you find an opportunity, "Percivars Ethics," from which
the Code was largely taken. You will also be interested in the "Good-
lye Doctrine and Instruction" of John Halle, part of which I had
published in C)p |g)|gfiaBn nk Snrgeon in February, 1905 (page 61).
There are also special books on the subject; for example, some for
Roman Catholic physicians, or those who practice in Roman Catholic
communities; some, entitled "Pastoral Medicine," written for priests,
who have to do a good deal of medical work. There are certain details
in the practice of medicine among Roman Catholics that differ from the
general; for example, abortion is absolutely prohibited, even if pro-
posed with the purpose of saving the mother's life. Then there are a
number of details regarding dangerous diseases that should be known,
especially the importance of having the clergyman called before the
patient's mind becomes obscured. Those who have acquaintances
among the priesthood would do well to learn all the details of such mat-
ters. It is not my purpose to go into details at this time.

Settling. — ^What are you to do when you settle in a place? Aside
from the ordinary business formalities, one of the first things is to call
on the other doctors. Very often this is not done. In ordinary society,
if I am correctly informed, it is the custom for the newcomer to be
called upon. In the case of the ordinary citizen, the neighborhood, or
the church or whatever other affiliations he may have, calls or sends its
wives to call on him or his wife, and many a young doctor has an idea
that the others ought to call on him first. But there are many reasons
why that should not be so. The doctors in a town are well known, their
names can be learned from the directory, or telephone directory, but the
newcomer is not known and unless he make himself known, he might
have to wait a long time, no matter how superior he was, before other
people would find out his mere existence. Therefore it is not only
rational but essential for a doctor settling in a new place to call on the
other doctors there because he is going to be one of them. And he
should make himself known as agreeably as possible, not as if he
expected them to hand over their practices, but as one man talking to
others in as modest a way as possible, not boasting of his advantages or
ability in any particular line, or the advance of medicine in which he has
participated, because after all those things smack of the freshman, no
matter how true they seem. And from the very beginning you should
get on good and friendly terms with other doctors. That is very often
not done and always with unfortunate results. People working in the
same profession ought to work together ; if any man from the beginning

MEDICAL ETHICS AND ETIQUETTE. 486

mikes up his mind that he is going to be friendly and forbearing raither
than otherwise, things will be very much better. One can see in various
towns very striking differences in the advantage of practice, depending
on whether the doctors in the town are on good termsl I advise men
who have asked me where to go never to go into a town where the doc-
tors are not harmonious but if they know where they are so, to go there
rather than to a place where they are always fighting. Quarreling
makes the profession less looked up to. It lessens the legitimate return
that one should expect from practice, as may be easily understood. The
beginner can sometimes make himself useful by offering to do, on busi-
ness lines, what the older and busier man has not time to do, although
he never should intimate the other does not know how to do it. Nor
should he overrate the importance of his part of the work, thinking that
because he can count red corpuscles he is an expert in blood diseases, or
because he can see hyaline casts that he knows more about the manage-
ment of a case of uremia than the older man. Good but injudicious
men have gone to offices of doctors in town or country and talked as
if the other doctor did not know a blood counter from a microtcwne and
very often have been introduced into better looking laboratories than
they saw at school.

Other questions often asked about are in regard to cards, signs, et
cetera. Those are all questions of local taste and custom. You should
find out about them from the doctors in the locality. In some places it
is customary to put a card in the newspapers; in others that is con-
sidered bad form, and even in little towns it makes a difference whether
you do the right thing or not. In some places doctors have signs that
look as if they might belong to a bath house ; in other places they have a
red light, that would in still other places invite a visitation from the
police. Those details you should learn, and not have a big sign in a
town wh^re it is the proper thing to have a small one. That would
make one appear as odd, and that is always a bad start for one to make
in any walk of life, and dangerous unless one has great talents and the
ability to make them known.

Practice. — Let us consider next the getting of the patients. The
things that govern the acquisition of a practice are too complicated to
enumerate in a short time. The reasons for a patient going to a doctor
are almost impossible to analyze, but a number of causes are sometimes
brought to my attention, and I shall try to explain them. The begin-
ner has an idea he cannot get any patients because the patients belong
to other people. That is by no means the case. It used to be so in many
parts of the world, and still is so in some parts, that practices were
bought and sold. It was formerly carried out most completely in Eng-
land, where even now it is rather unusual for a man to get into a prac-
tice without having paid for it ; but in other countries, as in Germany
and this country, it has been decided by courts that medical practice
cannot be a matter of sale in the ordinary sense. There is no exclusive

486 ORIGINAL ARTICLES.

right about it. So if A buys B's practice, C has a perfect right to start
in beside A and get all the practice he can. Whether it is a fair pro-
ceeding might be questioned, but the legality of it cannot be doubted at
all. But the patient never belongs to anybody. The sick man has a
right to go to anybody he pleases ; in fact, he has a right not to go to
anybody at all. Whether he is obliged to take his dependents to a doc-
tor has not been settled. A man may go to a doctor, an osteopath or
a Christian Scientist just as he chooses; but whether he has the right
of taking his child with diphtheria to an osteopath or Christian
Scientist has not been finally determined by the courts. It is
sometimes said — and I am sometimes asked about this — that one
should not take a patient without being perfectly sure that the patient is
no longer financially indebted to his previous doctor. That, however, I
do not think can be considered as very good doctrine. In the first place
when one is called to see a sick person it is not well to put the fiinancial
part first ; not well to ask, "Are you able to pay your bill," or, "do you
propose to pay your bill." You should find out what you can do for
him and do it. If you put everything on the ground of payment in
advance you certainly will not advance your practice very rapidly. On
the other hand, the patient who easily changes from one doctor to
another is not likely to do anybody much credit, so doctors should not
encourage that sort of thing. Sometimes the new doctor knows or
learns the patient already has a physician. In such cases patients should
rather be encouraged not to change without good cause but keep on
with anybody who is competent to treat them and willing to treat them.
Then there are other reasons why one should not too quickly or too
easily take up with a new patient, — ^geographical reasons or matter of
convenience. As a general thing a doctor should not make his practice
any more arduous than it has to be. To go ten or twelve miles out of your
way in the district of another doctor is not a good thing to do, not
because the patient has not a right to call you or you a right to go there,
but because while you are going ten or twelve miles in someone else's
territory you will lose time and perhaps practice in your own. So the
best doctors in city and country try to limit their territory and remain
on such terms of friendliness with their neighbors that if a patient calls
them up at a great distance they refer them to a neighbor, knowing
very well that in the long run these matters will become equalized.
Another point in regard to the selection of patients with reference to
their financial ability. It strikes me sometimes that there is a greater
tendency now on the part of young doctors to take that attitude than a
few years ago. I think the difference is due to changes in methods of
study. Up to a few years ago medical students saw more of the work
of practicing physicians than they do now. They saw charity work
done as a matter of course, and so carried out the same plan themselves.
I have known of men starting out on the "no pay, no treatment" plan,
who were soon obliged to migrate ; but learning their lesson and begin-

MEDICAL ETHICS AND ETIQUETTE. 487

ning anew in other places, they were able to get along in a better way.
There is one reason why a patient may change; that is the reason of dis-
like, with or without any cause, which is illustrated by the poem about
Doctor Fell. It was said first not about a doctor of medicine, but of
divinity, but illustrates the point very well. It runs :

I do not like thee, Doctor Fell,
The reason why I cannot tell;
But this I know and know full well,
I do not like thee. Doctor Fell.

Practice comes in very curious ways; not always from influential
people in the ordinary sense. For example, it is more likely to come
from a cook in a family than from the minister's wife or than from a
lodge brother's wife. I do not mean to say that the church and the
lodge should not be cultivated, but to cultivate them witfi the purpose
of gaining practice is not only ethically wrong but will be a disappoint-
ment in the long run. But however the patient comes to you, with or
without a discharge from his former doctor, no criticisms or comments
should be made in regard to the doctor. So far as possible his treat-
ment should not be criticized. Some men make a practice of disregard-
ing both these rules, either by direct statement, by facial expression, or
by the equally emphatic way of throwing medicine out of the window or
into the fire, or by ostentatiously changing the line of treatment, as by
giving one salt instead of another. In the case of a quack or pretender,
no effort should be made to protect him, especially by continuing a
faulty line of treatment, or you share his fault. On the other hand, it is
a waste of time to condemn him. People understand only results in the
treatment of disease, and cannot understand methods. This is well
shown by the answer of the blind man healed (John, Chapter IX) :
"Whether he be a sinner I know not : one thing I know, that, whereas
I was blind, now I see." The result in any case is not wholly in your
own hands. If you get credit, accept it pleasantly. If blamed, accept
the blame philosophically.

Concerning the freedom of patients in consulting their doctors, it
might be well to point out some local facts at this time. As all of you
know there is a good deal of opposition to the working of this hospital.
The ground is taken that the hospital is a charity hospital but abused by
rich people who come here and get their treatment at a nominal price.
The matter of abuse of charity hospitals is a very extensive one ; it hap-
pens everywhere, and every now and then a millionaire disguises him-
self, borrows somebody's old clothes and gets advice and treatment at
some great city hospital for nothing. But this hospital was never built
as a charity hospital, and any charity that comes out of it is purely cas-
ual and incidental, though the aggregate, as you know, is considerable.
It was not built as a hospital in the beginning; it grew up in response to
the need of a place for the care of people who came here for treatment
and advice. They came before there was any special building and lived

488 ORIGINAL ARTICLES.

in boarding houses and hotels and so a dinic grew up, but even now it
is not a hospital where a perfectly penniless person can come and be
taken in. This is undoubtedly unfortunate and should be remedied, but
that it is improper or that there is any irregularity or any ethical fail-
ing about it, nobody can say ; because just as a side man has a right to
go to a doctor in his own town or a distant town or to none at all or to
a Christian Scientist, so he has a right to go to the hospital where he pays
twenty-five dollars a week or to the one where he pays seven dollars a
week and is examined by half a dozen doctors or half a hundred medical
students. He sells his disability for a price, as he has the right. It is
for him to decide whether to pay twenty-five dollars, or any sum, for
service or to come here and get twenty-five dollars worth or more of
service for seven dollars, and submit to a public examination ; and if he
wants to do that nobody can object on the ground of ethics or legality.
In large cities there are men who make their living by serving in aus-
cultation and percussion courses, just as there are others, with chronic
diseases, who demonstrate the latter to classes for a price. Perhaps a
patient will leave your district and come, but it does not follow that that
represents a definite and actual loss to you. It is often the case that a
patient who does that would be on the point of going to somebody else ;
if he did not come here he would go to one of your neighbors ; probably
the reason he did not is that he thinks the neighbor is not as good as you
are, and that may be a consolation to you or may not. Now it undoubt-
edly is to the benefit of a practicing physician to have as many patients
as he has time to treat, and the way to have them is to make your
patients so comfortable that they would rather pay you any sum than go .
to a hospital for a smaller sum. And even after all that is done there
will be plenty of patients who can conveniently or advantageously be
sent to a place like this for treatment, and who can be sent without caus-
ing you any possible loss of income but actually, perhaps, aiding you by
leaving you free for other practice.

THE CLINICAL ASPECTS OF PARETIC DEMENTIA,
WITH SPECIAL REFERENCE TO DIFFER-
ENTIAL DIAGNOSIS.*

IRWIN H. NEFF, M. D.

It is manifestly impossible to attempt more than a reference to
facts pertinent to the subject-matter of this paper. Therefore I
shall dwell for the most part with generalities, referring only to the
more salient points bearing on the nature, pathogenesis, causation
and differential diagnosis of paretic dementia. A reference to the
recent and voluminous literature of paretic dementia is convincing

♦Read at the annual meeting of the American Medico-Psychological
Association, Boston, Massachusetts, June 12-15, 1906.

CLINICAL ASPECTS OF PARETIC DEMENTIA. 489

that although with reasonable certainty we can say that we have
definite and characteristic pathologic lesions, we have not solved
many questions concerning its nature, course, and clinical picture.

An unusual amount of labor has been expended in attempting to
establish a pathognomonic clinical sign for this disease; but one
must acknowledge that the clinical diagnosis is made on the correla-
tion of symptoms. The advent of the atypical case — ^the arterio-
sclerotic case — and the frequent appearance of analogous symptoms
in other cerebral organic diseases having a distinct pathology, has
made apparently an endless degree of confusion. The idea that
paretic dementia is an organic brain disease per se, with attend-
ant changes in the mental attributes is an old one, but many of us
today are again inclined to this belief. This theory is a plausible
one when we remember that we have other brain conditions showing
similar symptoms, — symptoms so closely resembling those found in
paretic dementia that we are often unable to determine the differences.

It has always seemed to me that we have attempted to surround
paretic dementia with a veil of mystery, and have patiently and con-
sistently endeavored to make all our cases conform to a certain type.
Why should we not have a variation in the mental syndrome? Such
a variation in symptoms may be found in cases of brain sclerosis,
brain timiors, arteriosclerosis, and even old cases of softening and
hemorrhages. If we recognize these inconsistencies occurring in the
course of these diseases, why not consider paresis as a disease which
can exhibit the same peculiarities.

F. W. Mott, seven years ago, advanced the theory, giving his
reasons, for supposing that general paralysis of the insane was a
primary degeneration of the neuron, with secondary inflammatory
changes. His conception of the disease, briefly expressed, was as
follows :

General paralysis is primarily a parenchymatous degeneration
due to loss of durability of the nerve cells and a premature decay of
tissue in which inherited and acquired conditions take part, with the
result that progressive death of the last and most highly developed
nervous structure ensues as soon as their initial energy is unable to
cope with the antagonistic influences of environment.

While the acceptance of such a theory might seem to add to our
confusion, I believe that a more general adoption of a theory com-
prehending Mott's main points might prove serviceable. By con-
forming to such an opinion many debatable points concerning the
disease could be more easily explained.

Some years ago I accepted this theory of paretic dementia as a
working basis, and have found that his conception of the disease has
proved of considerable aid in the clinical interpretation of the mental
and physical syndrome. The acceptance of such a theory might seem
to prohibit an accurate diagnosis of the paretic syndrome and prevent
a grouping of the disease as a psychosis. However, the classification

490 ORIGINAL ARTICLES.

of mental diseases is today an arbitrary one, and we now merely place
psychoses in groups if possible, leaving, if necessary, a large number
of cases unclassified.

RECAPITULATION.

Paretic dementia is a significant term, and should in the absence
of a more suitable name be retained in our nomenclature of the
psychoses. It should, however, be remembered that we have in this
disease a widespread organic affection, with changes accentuated in
the brain, but with demonstrable lesions in the diflFerent systems of
the body. It is known that in many cases of paretic dementia
vascular and visceral changes may be quite often detected, and for
this reason it is claimed by some that paresis is a specific systemic
disease and must have an isolated etiologic agent. I would, how-
ever, suggest as opposed to this a comparison of the more general
morbid lesions found in paretic dementia, with pathologic lesions
detected in other organic brain diseases. Until such a comparison
is made and proper deductions induced it seems to me that we are
justified in considering paretic dementia as an organic brain disease,
with superimposed mental symptoms. Such an opinion does not
destroy the morbid entity of the disease, but allows us more latitude
and gives us an opportunity to more thoroughly recognize why we
have in this disease a disease of protean form, with a syndrome show-
ing many consistencies and contradictions. If we are inclined to such
a belief we are more prepared to admit that the differential diagnosis
of paretic dementia may clinically be a matter of extreme difficulty.

The frequent occurrence of the anomalous case of paretic demen-
tia, the increasing frequency of the early adult case, and the more
thorough individual analysis of our cases of general paralysis of the
insane indicate that there must be widespread and varying etiologic
agents.

It is interesting to note as bearing upon Mott's idea of the disease
that heredity is now recognized as an important predisposing agent.
We have made an investigation and believe that heredity is a factor
of importance, and may be regarded in many cases as a true predis-
posing cause. We also believe that heredity in these cases is similar
to the heredity observed in other organic nervous affections. A con-
sideration separately of the many causes advanced for the production
of paretic dementia makes it more apparent that in this disease we
have a predisposition, which in a considerable number of cases may
be inherited.

We are not yet prepared to say with certainty that we can isolate
the condition or factors responsible for the development of general
paralysis of the insane. In common with other organic brain disease
it is probable that there are many causes acting directly and indirectly
to produce the disease. The apparently clear diagnostic points which
are advanced for the purpose of distinguishing paresis from other
diseases are at times of little value, and I think that manj of us will

CLINICAL ASPECTS OF PARETIC DEMENTIA. 491

admit that we place these doubtful cases either in organic dementia,
or more particularly perhaps leave them unclassified.

When differentiating this disease clinically, as is well known, we
bear in mind, first, the character and degree of mental involve-
ment ; second, the presence or absence of physical signs. To this we
must add the knowledge gained from lumbar puncture. The feasi-
bility of lumbar puncture and its practical application in diagnosing
the .organic insanities, and particularly in distinguishing the organic
from the nonorganic psychoses, cannot be doubted; but, as with
other clinical methods its limitations must be remembered, and our
findings considering our present understanding of this procedure
must receive careful attention. This diagnostic method, however,
has already proven of value and is worthy of more extended use.
We have made it a routine measure, and we believe it has assisted us
in differentiating the simple insanities from the mental affections hav-
ing an organic basis. The results we have obtained, however, have
been substantiated by other clinical examinations.

It must be acknowledged that we have no one pathognomonic
clinical sign and our "positive signs" after all are only suggestions.

Summarizing these brief remarks on the differential diagnosis of
paretic dementia, I would say that the inconsistencies manifested in
the clinical syndrome of the disease make it imperative that we
diagnose by correlation of symptoms. Certain mental and physical
signs occurring during the course of the malady may be highly sug-
gestive but are not conclusive. We should always guard against
placing undue importance on one symptom. Lumbar puncture in
the organic psychosis offers a field for research and may prove to be
a valuable diagnostic agent.

GENERAL CONCLUSIONS.

(i) Paretic dementia is an organic brain disease, with super-
imposed mental symptoms.

(2) The clinical inconsistencies frequently observed in paretic
dementia and the presence of analogous symptoms in other organic
brain diseases make it seem improbable that in paretic dementia we
have a definite mental entity directly related to the disease. The
variability of the mental symptoms thus expressed has its analogy
in other brain affections.

(3) In common with our knowledge of other organic brain diseases
with attendant mental changes, we may regard the paretic syndrome
as capable of being produced by numerous causes.

(4) Heredity of indirect type is probably a not infrequent pre-
disposing element to the disease.

(5) The clinical differentiation of paretic dementia is often impos-
sible. The late appearance of the so-called characteristic mental and
physical signs may prohibit a concise diagnosis.

(6) The diagnosis of paretic dementia should only be made by a

4d2 ORIGINAL ARTICLES.

correlation of the mental and physical signs. There is no one pathog-
nomonic clinical symptom.

(7) The differential diagnosis, clinically, is often a matter of
extreme difficulty: the distinction from arteriosclerosis of the nervous
system, brain syphilis, chronic alcoholic insanity, with organic brain
changes, cerebral tumors, and brain sclerosis may be impossible.
Such a differentiation is particularly difficult in the early or incipient
stages of these diseases.

(8) If we consider paretic dementia as an organic brain disease,
the mental changes being secondary, we can more easily recognize
and appreciate the vagaries of the malady. By comparing the mental
symptoms observed to those occurring in other organic brain diseases
we are more clearly impressed with the fact that in a case of paretic
dementia there can be no well-defined clinical picture. Of necessity
we must have multiform mental and physical signs.

Pontiae, Michigan. _

THE VARIOUS GROSS PATHOLOGICAL CONDITIONS OF

THE URETHRA AS REVEALED BY THE

URETHROSCOPE.*

NOAH E. ARONSTAM, M. D.

mornsoR or dirmatologt in ths Michigan collbgb or mkdicins and susgsrt.

The urethroscope is 'a valuable means in the diagnosis of the
various pathologic conditions affecting the male urethra. What may
seem obscure on a cursory examination, may, with facility, be recog-
nized when the above instrument supplements our investigations. The
affections of the urethral canal are not as uniform as it was commonly
believed heretofore, as a great number of causes may give rise to
identical symptoms. Should we fall into the routine of treating the
effects instead of the causes, the results will be far from satisfactory.

The rational and appropriate treatment of the different morbid
states of the urethra presupposes ( i ) a knowledge of the technique of
urethroscopy, both anterior and posterior; (2) a familiarity with the
normal and pathologic aspects of the canal; and (3) the particular
method of treatment suitable to each individual case.

We distinguish between anterior and posterior urethroscopy. The
former constitutes the examination of the anterior urethral segment,
that is, the first six and a half inches of the canal, while the latter is
directed towards the exploration of the remaining one inch and a half
of the urethral tract.

The following is the technique of urethroscopy, both anterior and
posterior :

It is superfluous to say that the urethroscopic tube — the anterior
of which is straight, while the posterior is somewhat curved, with a
fenestrum in its curve — ^must be scrupulously clean and thoroughly

*Read by invitation before the Northern Tri-State Medical Association at
Put-in-Bay, Ohio, July 31, 1906.

CONDITIONS OF THE URETHRA 493

Sterilized in boiling water. After having sufficiently cooled down, it
is lubricated with a lubricant composed of a decoction of Irish moss,
to which a small quantity of some antiseptic agent has been added.
The patient is then put in the recumbent posture, the meatus and
glans penis cleaned with a mild antiseptic, and the tube introduced
gradually and slowly without much effort on the part of the operator.
No force should be used in inserting these tubes, save the most gentle
propelling motion, taking care not to lacerate the delicate mucosa of
the urethra. Should the canal prove impassable on account of an
abnormally small calibre or the presence of stricture, it should be ,
previously made patulous by gradual or forcible dilatation with sounds
until it admits number twenty- four (French), when the urethroscope
will readily enter the canal ; the obturator is then withdrawn, the little
lamp inserted, the coil attached at both ends and the battery turned on,
when the lumen of the canal will spring into view. If the patient is
very nervous the canal may be anesthetized with a two per cent
solution of cocain. The normal appearance of the urethra is that of a
uniform pinkish hue, without any appreciable variation throughout its
length.

The scope of this paper does not permit the author to enter
into an exhaustive discussion of the different lesions elicited in the
anterior portion of the urethra by urethroscopy. However, the most
salient features of the different pathologic conditions will be briefly
enumerated :

( I ) An abrupt change of the pinkish hue of the mucous membrane
to that of an anemic or colorless shade would suggest a stricture in
its formative or organized state.

(2)* Small punctcB studded here and there throughout its extent,
indicate an acute or subacute inflammation.

(3) Livid areas denote a chronic inflammatory state of the urethra.

(4) Granular spots are not infrequently detected; they are of great
significance, as they suggest an affection sui generis, termed granular
urethritis, a malady very obstinate and resistent to treatment.

(5) Lines or bands of a dark red color, which may be regarded as
the formative stage of the so-called linear stricture.

(6) Superficial erosions, commonly found within the first inch and
a half of the urethra near the fossa navicularis.

(7) Ulcerations of various types, both superficial or deep, may also
be discerned by the urethroscope.

The tube is gradually withdrawn after the fenestrated field has
been thoroughly inspected, until the entire length of the urethra has
been successively viewed. The small lamp causes but little heat and
occasions no irritation or sensation of burning. Should, however, the
patient complain of a smarting or burning feeling, then the battery
should be turned off for a moment, after which inspection may be
resumed.

After the tube has been withdrawn, the meatus and glans are again

494 ORIGINAL ARTICLES.

washed with some antiseptic solution and the patient given a capsule,
composed of two grains of quinin sulphate and five grains of urotropin,
in order to prevent urethral chill, which is occasionally apt to ensue in
nervous individuals. Urethroscopy should never be attempted in acute
inHammatory conditions of the canal, lest a great deal of harm be
created in doing so.

Urethroscopy is a diagnostic means of especial value in chronic
inflammatory states of the posterior urethra, preeminently so in
granular inflammatory involvement of the latter. To detect and prop-
erly interpret the particular morbid conditions aflFecting that part of
the canal means half of the cure achieved. The lesions of the posterior
urethral tract are nearly the same as those already mentioned in dealing
with the anterior urethra, with the exception of erosions and ulcer-
ations, which are not so prone to appear in that particular location.
Once the morbid condition ascertained, the treatment readily suggests
itself to the intelligent physician.

To enter into a full discussion of the latter will require more time
and space than has been allotted to the author under the present circum-
stances. Suffice it to state, however, that the eradication of certain
pathologic states, as determined by the urethroscope, is but a question
of time and perseverance on the part of both patient and physician, so
greatly is the treatment facilitated by the procedure above delineated.

Detroit, Michigan, io6 East High Street

MEDICOLEGAL QUESTIONS.

E. S. McKEE, M. D.

Professional Secrecy. — An interesting decision of fundamental
importance was lately given at the high court of justice at Leipsic. A
woman had contracted syphilis from a man and after his death recov-
ered damages from his brother and heirs. The medical attendant of
the deceased was summoned as a witness, but declined to give testi-
mony on the ground that the law imposes silence on medical men in
regard to facts concerning their patients. The plaintiff's council, on
the other hand, claimed that the law of secrecy was no longer binding
after the patient's death. The court decided that only the patient
himself was competent to release his medical attendant from the obli-
gation of professional secrecy, and since he had not done so it was
presumed that he did not wish the facts concerning his illness to be

made public after his death.

i¥ * *

Civil Responsibility and Syphilitic Infection. — M. Thibierge read
a most intersting paper on this subject before the Paris Society of
Legal Medicine. He said that in case of sexual infection action is
very seldom brought, for legal proof is decidedly difficult to obtain.
Cases of infection through employment arise almost exclusively among
glass blowers. A recent judgment of the court of compensation has

MEDICOLEGAL QUESTIONS. 495

brought such cases under the Workman's Compensation Act, although
formerly they were considered to come under another act. These are
the cases of the wet nurses who contract S)rphilis. The nurse can only
obtain damages by furnishing proof that the persons who engaged her
to nurse the child were imprudent or negligent, and also that they
knew of the possibility of the child being syphilitic. So in two recent
cases the parents were not assessed damages for they were able to
show that they did not suspect that they were syphilitic, and they called
experts to witness that there were no evidences of syphilis about them.
In both cases the children were evidently suffering from hereditary
syphilis. Such dcisions are possibly correct law, but they are not
humane, and some way of solving the problems should be found whidi
would give more justice to the sufferers than does the present law.

4c * *

Photographing the Dead for Identification. — The London Laticet
states that the coroner has on two recent occasions commented on the
unsatisfactory character of the photographs of the unidentified dead
taken by the police authorities. It adds that Doctor Miniovichi has
contributed a valuable report on this subject from his experience as
director of a Medicolegal Institute of Bucharest. He describes his
method in the Archives d' Anthropologic Criminclle. He substitutes
artificial eyes and gives a natural appearance to the lids by means of
lead foil or by pinning them to the eyeball with small pins. The jaws
are drawn together with threads, and the face drawn to a natural
expression by means of pins, evacuating accumulations of gas by means
of incisions in the scalp or mouth. He gives photographs of the
various steps in photographing the dead and states that he was able in
one case to fully establish the identity by means of the photograph, the
body having been in the water for six weeks.

♦ « «

Penalty far Selling Cocaine. — A Norfolk, Virginia, druggist was
fined $i,ooo and costs for selling cocain illegally. This is the maxi-
mum penalty in Virginia.

« ♦ ♦

Interstate Prescriptions Affected by New Drug Law. — ^The ques-
tion of physicians' prescriptions has been brought before the com-
mittee in charge of the new Pure Food and Drug Law and they refused
to exempt these prescriptions from coming within the scope of the law.
This would mean that any prescription put up and sold in any state,
territory, District of Columbia or insular possession and sent out to
another state, et cetera, or any foreign country, "must bear a state-
ment on the label of the quantity or proportion of any alcohol, opium,
morphin, cocain, heroin, alpha or beta eucaine, chloroform, cannabis
indica, chloral hydrate, or acetanilid or any derivative or preparation
of any substances contained therein. The solution of this complication
by the commission which has charge of the enforcement of these regu-
lations will be watched with, interest.

496 ORIGINAL ARTICLES.

Expert Testimony in Cases of Alleged Insanity. — This subject has
become of interest of late owing to the release of a patient from the
New York Asylum for Insane Criminals on his confession of murder,
and his subsequent commitment to prison on his acknowledging that
he had feigned insanity on his examination by the experts at his trial.
The experts were two of the leading authorities in the city and the
methods of the criminal seem to have deceived them. Interest has
been intensified by the occurrence of the recnt Thaw case. Interest is
also added to the case by an incident in a recent trial for murder
during which one of the most prominent medical experts changed his
opinion as to the sanity of the criminal appearing, in fact, first on the
one side, then on the other. Various methods have been proposed to
remedy the evil. That which receives most favor is the creation of a
state tx>ard of medical experts under rules and regulations established
by the state. It is contended that such a state board would be carefully
selected as to its membership, and if the compensation were fixed by
public authority and paid out of the public treasury, impartiality would
be secured. ' * * *

Dental Bill in Court. — The $i,ooo dental bill of Prince Louis, of
Battenberg, while being feted in New York, is outdone. Doctor
Robert E. Payne, another New York dentist, has brought suit against
Mrs. Jennie Wheeler, an artist of that city, for $1,505 for three
weeks' work on her teeth. Mrs. Wheeler, though fortune's wheel has
been kind to her, refuses to divide up with the dentist, asserting that
the price was to have been $500 and that the work was unskillfuUy
done. She also objects to paying $15.00 per hour for professional
services when they were taking lunch together and $52.50 per diem on
occasions when she failed to appear at the office for treatment.

* * *

Who Owns the Extracted Tooth? — The German courts have had
this question up before them recently. The dentist contended that the
tooth had been evicted from occupancy with the full consent of the
landlord, and had become ownerless and derelict, and as the patient's
tooth in question was curiously shaped and valuable to him as a speci-
men he proposed to keep it. The patient won the controversy, the
court deciding that the tooth belonged to the patient after it left the
jaw as well as before. This is certainly as it should be, but the patient
should be willing to devote a portion of his anatomy to science and be
proud of the distinction. :<« * *

Tooth In Bronchus. — A firm of dentists in Los Angeles extracted
seven teeth from a man and allowed one of them to drop into his
bronchus. He sued for damages and was awarded two thousand four
hundred dollars. An appeal from the verdict was not granted.

Hi Ha Ha

Pure Food Bill. — The enactment by congress proscribes interstate
commerce in patent medicines unless a full formula as regards alcohol

CLINICAL SOCIETY. 497

and poisonous drugs is stated upon the label. The law provides
against the shipping of proprietary medicines from one state into
another. The manufacturing of such medicines, like their sale, is not
prohibited within the state, hence the necessity of every state protecting
its citizens. It can be depended upon that the dope will be manufac-
tured in the state in which it is sold if there is no state law with this
requirement as to labels.

« :(i 4c

Headache Powders Again, — Mr. Wolf, a prominent merchant of
Findlay, Ohio, died after taking "safe, sure, and reliable" headache
powders sold by a local druggist. He was found dead with an empty
powder paper beside him. He had no means of knowing the condition
of his heart and circulation, and neither had the druggist who sold
him the poison. The druggists and nostrum vendors cry about inter-
ference with personal liberty. What about the poor victims and their
families? Are they to have no consideration at the hands of the state?

« « «

Syphilis in Relation to Crime, — This subject is very exhaustively
treated by Ravogli {Ohio State Medical Journal). He claims that
syphilis in the acquired and hereditary forms has increased crime and
may therefore be considered as one of the predisposing causes to
criminality. The syphilitic toxins carried in the circulation in the
secondary period are frequently the causes of neuroses. He traced
history and ascribes the butcheries and crimes of the fifteenth century
to be due to acquired and hereditary syphilis. It is a good argument
to connect so terrific an epidemic of crimes with syphilis, recalling the
time in which it was enacted, just after the spreading of syphilis
epidemically.

Cinciunati, Grand and Nassau.

TRANSACTIONS.

CLINICAL SOCIETY OP THE IV^IVERSITY OP MICHIGAN.

STATED MEETING, NOVEMBER 7, 1906.

The President, HUGO A. FREUND, M. D.. in the Chair.
Reported by DAVID M. KANE, M. D., Secretary.

REPORTS OF CASES.
TUMOR OF ORBIT.
Doctor Walter R. Parker : I wish to exhibit a patient on whom
I performed a Kronlein operation for the removal of a tumor from
the orbit without injury to the eyeball. A male, aged thirty-four, gave
a history of exophthalmos, gradually increasing during the past twelve
years, with attacks of acute mania during the past six years. There
was no pain nor discomfort except from double vision; no fundus
changes; vision about normal. The patient being illiterate and men-

408 ORIGINAL ARTICLES

tally substandard, accurate results could not be obtained. The eyeball
was displaced outward about three-quarters of an inch, and downward
about one-half of an inch. A distinct tumor could be felt deep in the
oH[>it which appeared to communicate with a nodule about the size of a
marble situated upon the brow just above the supraorbital notch.

After consulting with Doctor Canfield to exclude the accessory
sinuses as a possible origin of the tumor, it was decided to remove the
nodule from the brow and determine the nature of the growth. While
the patient was under the anesthetic, deep palpation revealed the fact
that the orbital tumor was movable.

The report from the Pathologic Laboratory on the nodule removed
from the brow was fibroma, possible neurofibroma.

The diagnostic points were as follows :

(i) A nonmalignant growth, as revealed by the history and path-
ologic report.

(2) The displacement of the globe outward and downward indi-
cating that the tumor was situated outside and above the muscle cone.

(3) It was movable.

An osteoplastic flap was made after the method of Kronlein. A
curved incision was made beginning over the temple extending along
the outer margin of the orbit, dividing the periosteum, then backward
along the upper edge of the zygomatic arch.

The periosteum lining the inner side of the outer wall of the orbit
was retracted together with the orbital contents. The lateral wall of
the orbit was cut through with a chisel in two places. Above in the
suture between the great wing of the sphenoid and the malar bone
and below in a horizontal plane passing outward in a line directly
above the insertion of the zygomatic arch. This piece of bone with its
muscle and cutaneous attachments was forced backward giving free
access to the orbit. The periosteum was divided in a horizontal
direction and the tumor dissected out. After removal of the tumor the
periosteum was sutured with catgut, the bone and soft parts replaced
and the latter sutured with silk, and dressings applied.

Union was perfect and recovery uninterrupted. The excursion of
the eyeball is perfect and the vision the same as before the operation.

The tumor measures thirty-five by twenty-five by nine millimeters
and apparently has its origin in the frontal branch of the fifth nerve.
It will be sent to the Pathologic Laboratory for examination «nnd a
detailed report will be given later.

DISCUSSION.

Doctor R. Bishop Canfield: There is great difficulty in the
diagnosis in such a condition. The first Kronlein I saw was by
Kronlein himself. He found nothing but congestion. The case
turned out to be polyp of the sphenoid, causing the congestion and so
the ptosis. Another point to be observed, is that in almost all cases
where the condition is caused by disease in the accessory sinuses, there

CLINICAL SOCIETY. 499

is an inflammatory reaction. There was no evidence of inflammation
in this case and the accessory sinuses showed no evidence of disease.

Doctor Reuben Peterson : I would like to ask why there is no
pain from so distinct an involvement of the supraorbital nerve.

Doctor Solis: We usually find excessive pain associated with
such a growth. This is probably due to the pressure of the growth
on the surrounding tissues.

Doctor Parker: There is rarely or never pain in multiple fibro-
mata. They are in fact fibromata arising from the fibrous sheath of
the nerve, and not true neuromata.

NEPHRECTOMY FOR HYDRONEPHROSIS DUE TO RENAL CALCUU.

Dqctor Reuben Peterson: I have an interesting specimen to
present, a case of stone in the kidney, giving rise to hydronephrosis
of marked size. The kidney tissue has almost disappeared, the pockets
or loculi being of immense size when filled. An interesting point is
that this long, peculiarly-shaped calculus blocked up^the ureter com-
pletely so that there was absolutely no communication between the
pelvis of the kidney and the ureter. I also call your attention to
a stone lying in another pouch. This specimen was removed from a
woman of forty-seven, whose previous history had been in every way
normal, except that for the last ten years she had noticed in the right
side, especially in the flank, occasional pains, but never to a marked
degree. She had complained that when in bed there was a sense of
discomfort at this point.

Two months ago she noticed a tumor just under the right ribs,
which has grown rapidly since that time. I saw the patient a week
ago. At that time there was a tumor which did not distend the
flank to any great degree. It went beyond tlie median line and down-
ward to the anterior superior spine. The circumstances were such
that I could not make an examination of the ureters. The patient
was extremely fleshy so that I could not determine with any degree of
certainty whether the growth was cystic or solid. The intestines
covered the growth, so we were dealing evidently with a retroperito-
neal growth in the neighborhood of the kidney or with a cystic kidney.
My diagnosis was probable cystic kidney, possibly a retroperitoneal
growth in connection with the kidney.

Then came the question of the operative route. It reached so far
over in the median line that it seemed to me better to get at it by the
transperitoneal route. An incision was made frcMn the edge of the
ribs downward at the outer edge of the rectus. The incision through
the peritoneum was made well outside. There was great difficulty in
enucleating on account of 'the adhesions, which shows the advisability,
in these large growths with adhesions, of adopting this route in prefer-
ence to the extraperitoneal route. I think it would have been more
difficult by the other operation. I drained posteriorly and also ante-
riorly, and sutured up the peritoneum.

500 ORIGINAL ABSTRACTS.

The woman has done very well since the operation. The gall-
bladder was filled with calculi — there must have been twenty or more.
I decided that inasmuch as the patient had never given any symptoms,
we would leave them alone, as her condition at the completion of the
rather long operatito was none of the best.

DISCUSSION.

Doctor Cyrenus Darling: I think that everyone who removes
a kidney and the patient recovers, thinks that is the easiest way.

Doctor Charles B. G. de Nancrede: I think when the absence
of pus can be determined, the transperitoneal route is preferable. If
one has to deal with a large tumor, by making a straight transverse
incision, going, if necessary, past the median line, gives greater ease
in reaching the pedicle. One can see what he has, and can control
the hemorrhage more easily. Still, experience has shown that through
the posterior route we can take out the large adherent tumors piece-
meal without having much additional hemorrhage.

READING OF PAPERS.
**SOME CARDIAC ARHYTHMIAS:'

Doctor Lawrence C. Grosh, of Toledo, Ohio, read a paper on this
subject. (See next issue of %\t |p|KftciRn anb jhngton.)

ORIGINAL ABSTRACTS.

SURGERY.

frank banghart walker, Ph. b., m. d.

nOVBaSOR op SUSGBKT and onitATIVB SURGBBT tM THB DBTBOIT POBTGBADUATB SCHOOL OF MBDICINB:
ADJUNCT FBOPBaBOB OB OPBBATIVB SUBGBBT IN THB DBTBOIT COLLBGB OP MBDICINB.

AND

CYRENUS GARRITT DARLING. M. D.

CLINICAL PBOPBttOB OP SUBGBBT IN THB UNIVBBSITT OP MICHIGAN.

EXOPHTHALMIC GOITRE.

There were three papers read before the Section on Surgery and
Anatomy of the American Medical Association, at its last meeting, on
"Exophthalmic Goitre," that clearly express (Journal of the American
Medical Association, September i, 1906) the present idea of the profes-
sion concerning this disease and the newer methods of its treatment.

The first article, by John Rogers, M. D., of New York, is on the
treatment of thyroidism by a specific serum. He would discard the term
exophthalmic goitre and designate the condition by the word thyroidism,
modifying it by such variations as hyper, atypical, chronic toxic, acute
toxic, and psychopathic or neuropathic. The symptoms which charac-
terize each classification are carefully noted, an arrangement necessary

EXOPHTHALMIC GOITRE. '601

in order that individual cases may receive treatment indicated for the
particular case. In certain cases he has employed a serum of his own
with favorable results. It is obtained from the blood of animals (rab-
bits, dogs, and sheep) inoculated with nucleoproteids and thyroglobulin
from the himian thyroid gland. When injected into the patient this is
supposed to have a specific effect on thyroidal epithelium. The best
results are obtained where one cubic centimeter of the serum is injected
every third or fourth day until from four to eight injections have been
administered. Reaction is noticed by a burning sensation at the
point of injection, followed in a few hours by swelling and redness, later
by fever, with rapid pulse. He reports ninety cases treated ; twenty-
three cured, fifty-two improvements, eleven failures, and four deaths.

Improvement is indicated by changes in the size and character of
the thyroid. Large soft glands become smaller and harder, while a
hard gland will become softer. Chronic cases past middle life, with
hard glands, when not benefited by a month's treatment may consult a
surgeon.

The second article, by S. P. Beebe, M. D., Ph. D., of New York,
deals with the preparation of the serum mentioned in the previous
paper. The first products were made from normal human thyroid
glands obtained at autopsy. These contain a very small amount of
nuclear material and a relatively large amount of colloid. The method
of preparation is given in detail but is too extensive to be repeated here.
The material thus prepared from the glands is injected into the peri-
toneal cavity of dogs, sheep, and Belgian hares. Rabbits are given five
injections six to eight days apart and eight days after the last injection
the animal is exsanguinated.

Other preparations were made with pathologic human glands
removed at operation and from these he obtained the most active serum.
No marked clinical difference was found in the results whichever senmi
was employed, except. that where the normal ceased to do good the
serum prepared from pathologic glands would show marked results
when employed in its stead. The degree of actvity differs according to
the animal used in producing the serum.

The title of the third paper is "The Surgical Treatment of Exoph-
thalmic Goitre," by Francis J. Shephard, M. D., of Montreal. Opera-
tive treatment, while comparatively new, is not yet conceded by all as the
best means for relief though many cases of complete cure have been
recorded. Operation is based on the opinion that the' disease is due to
increase of thyroid tissue, hyperactivity or hypersecretion. Early opera-
tion is advised when the condition is not too severe, also in cases where
the enlargement is greater on one side, not excessively vascular, and
where symptoms of Graves' disease have preceded by months the tumor
formation.

Operation should be avoided in large vascular thyroids with definite
febrile exacerbations and excessive tachycardia, with acute dilatation of

602* ORIGINAL ABSTRACTS.

the heart, precordial distress, gastric and abdominal pain, vomiting and
diarrhea, sleeplessness, pers^nration, sense of suffocation, great restless-
ness, edema of the feet — in fact all the symtoms of toxemia due to
thyroidism. Most physicians are opposed to operative measures and
nearly all recent medical writers <mi exophthalmic goitre ccMidemn sur-
gical procedures as being too dangerous and not always successful.

Statistics are of little value in estimating the mortality from opera-
tions as much depends upon the case in question. General anesthesia is
looked upon by some as greatly increasing the danger. Collected cases
by most experienced operators give a mortality of six to eight per cent.

In discussing these papers Doctor Ochsner, of Chicago, said that
there were four distinct dangers connected with anesthesia for the oper-
ation. Unless anesthetized with great care patients may be so thor-
oughly asleep that it will be difficult or impossible to arouse them.
There is danger of producing a toxemia by violently handling the gland
while the patient is asleep, as well as of injuring the recurrent laryngeal
nerve. There is also danger of infecting the wound through the
patient's breath. Doctor Bacon believes that the line of progress in the
surgical treatment of exophthalmic goitre will lie in a more careful
analysis of the cases. Doctor Dawbam advocated the ligation of the
superior and inferior thyroid arteries on both sides as a safe operation,
devoid of mortality, with no resulting deformity or mutilation. They all
spoke favorably of the serum although they believed it to be in the
experimental stage and advised operation in selected cases where the
serum failed. c. g. d.

GYNECOLOGY,

REUBEN PETERSON, A. B., M. D.
novnsom op gthscologt and obstbtrics in rum unxvbmitt or Michigan.

AND
CHRISTOPHER GREGG PARNALL, A. B., M. D.

FORMBIILT FIRST ASSISTANT IN GTNSCOLOGY AND OBSTBTRICS IN THB UNIVBRSTTT OF MICHIGAN.

ARTIFICIAL RENAL COLIC AS A VALUABLE MEANS OF

DIAGNOSIS.

HuTCHiNGS (Atnericcm Journal of Obstetrics, Volume LIV,
Number III) continues Kelly's observations on the production of
artificial renal colic, published first in May, 1899. One hundred cases
in all were studied, being selected from one hundred fifty examinations
made in Kelly's clinic. These examinations were made with a view
to locate the cause of various pains in the abdomen and back when they
could not be explained by ordinary methods of diagnosis. Aside from
pains with definite locations are those of an indefinite character located
in various regions of the body and not diagnostic of any one lesion.
These pains may be met with under a variety of pathologic conditions

ARTIFICIAL RENAL COLIC. 50S

such as disease of the appendix, of the gall-bladder, the Fallopian tube,
the kidney, the pleurae, et cetera. The method employed to produce
an artificial renal colic, to compare with the pain complained of, after
a careful history is taken and a thorough examination is made, is to
explain to the patient that a cystoscopic examination is to be made, but
she is not warned that her original pain may be reproduced. With
the patient in the knee-chest position the ureter of the affected side is
catheterized. The catheter should reach the kidney pelvis and should
never be forcibly inserted. The patient now assumes the dorsal recum-
bent position. The bladder is catheterized, and the urine from the
ureteral catheter collected and examined. Warm methylene blue
water is now injected slowly, by means of a glass syringe, into the
ureteral catheter until the patient begins to feel pain. As soon as the
pain is definite the desired information is obtained and relief immedi-
ately follows the release of the fluid.

The repeated injection of normal renal pelves has shown that
pain in the back, just below the twelfth rib, is first experienced. The
pain then extends anterioriy over the abdomen and then down the
iliac crest and in the direction of the ureter, becoming more and more
severe, as the injection proceeds, until a typical renal crisis is produced.
If the pain caused by the injection is the same as that of which the
patient originally complkins, a diagnosis of renal disease is made.

The writer groups the one hundred cases under the following
heads :

I. Normal kidney pain produced. Not that pain of whicfi the
patient complained. Disease of the kidney ruled out.

II. Kidney pain reproduced; Same pain as that of which patient
complained. Diagnosis of renal or ureteral disease confirmed.

III. Dilated pelvis of kidney. Stricture of ureter.

IV. Doubtful cases and failures.

Group I, twenty-three cases. — ^Typical kidney pain in all from
injection. Located in "superior lumbar triangle." In none corre-
sponding to the original pain. In seven cases the pain was found to
be due to pelvic disease, in six to disease of the appendix, in six no
diagnosis was made, and in two, operations showed nothing to account
for pain.

Group II, fifty cases. — In all, the typical renal pain was reproduced
and recognized as the one originally complained of. In thirty-five
cases movable kidney was diagnosed and suspension done. In eight
cases operation for movable kidney was refused. In two, treatment
by bandage was advised. There were three cases in which nephrot-
omy was done with relief of symptoms. Suspension of the uterus in
one instance and removal of the appendix in another failed to obtain
relief for pain.

Group III, seventeen cases. — For various reasons in ten cases no
operation on the kidneys was performed. Of the remaining seven

504 ORIGINAL ABSTRACTS.

cas^s, the kidneys were suspended and the renal pelves folded in one ;
the stomach, kidneys, and liver suspended in another ; ureteral calculi
removed in two; transplantation of the ureter in one; stricture of
ureter relieved in one ; and the kidney removed in one case. Thirteen
of this group of patients complained of pain which was reproduced by
injection.

Group IV, ten cases. — In six the answers of the patients wefe so
unsatisfactory, and the location of the pain so vague that no positive
diagnosis could be made. In three cases the same pain was repro-
duced; in one omental adhesions were found, in another gall-stones,
and in the third no explanation for the pain could be conjectured.
To sum up, the author arrives at the following conclusions :
(i) The ability to reproduce, mechanically or otherwise, the pain
of which the patient complains is always a most valuable aid in
diagnosis.

(2) A definite and typical "kidney pain" (renal colic) can be pro-
duced in every instance by forcibly distending the pelvis of the kidney
with a bland fluid.

(3) In a large majority of cases (ninety-eight per cent in our
series), patients are able to accurately differentiate renal pain, caused
by the method described above, from pains from other causes.

(4) By this method a diagnosis can frequently be made in a class
of cases, as yet undifferentiated by the medical profession, whose
symptoms are vague and indefinite.

(5) Accurate measurements of the amount of dilatation of the
pelvis of the kidney may be made with the instnmient used, and by
this means valuable data are obtained. c. a p.

Jackson, Michigan,

PEDIATRICS.

ARTHUR DAVID HOLMES, C. M., M. D.

TYPHOID IN CHILDREN.

Butler {Jama, November 11, 1905). The author reviews the
literature thoroughly with reference to the frequency, causation, et
cetera, and gives an analysis of two hundred ten cases of typhoid
fever in children — one hundred six boys and one hundred four girls.
The average duration of symptoms, such as restlessness, headache,
vomiting, anorexia, fever, et cetera, before coming under observation
was seven days. In one hundred seven of the cases the bowels were
regular in seven, constipated in thirty-one, and sixty-nine had
diarrhea. Nosebleed occurred in twenty-nine of the two hundred
ten. Tympany of varying degrees was usually present . after the
first week, and in some cases was an annoying symptom, extending

WEIGHTS OF VISCERA IN INFANCY. 506

into convalescence. Roseola was found in one hundred fifteen out
of the two hundred ten cases, but seldom before the sixth day of
the disease. The average duration of the temperature in all cases
was 17.3 days. The Widal test was positive in eighty-six of the
ninety-six cases examined. The mortality, as usual lower in children,
was 5.2 per cent. Intestinal hemorrhage occurred in thirteen patients,
four of whom died. Details of the fatal cases are given. The treat-
ment was symptomatic and hygienic. The author believes that the
enlargement of the diet of typhoid patients advised by many is unad-
visable so far as children are concerned. Milk diluted for infants
and very young children with albumen water and the usual cereal
gruel diluents, such as barley water and rice water as drinks, he
thinks, are best for this class of cases. Care in diet during the early
part of convalescence is as important as during the height of the
attack. Hydrotherapy was employed : tubbing in practically all cases,
the temperature being the usual guide to its employment; also the
nervous symptoms, which it seemed to benefit. In cases of severe
intoxication enemas of salt solution were used with advantage. Intes-
tinal antiseptics — salol, acetezone, et cetera, — did not seem to be of
any particular advantage. Four patients died from perforation, two
of whom were operated on.

THE WEIGHTS OF' THE VISCERA IN INFANCY AND

CHILDHOOD.

David Boviard and Matthias Nicoll, Junior {Archives of Pediatrics,
September, 1906), recognizing the need of some definite standard of
the weights of the viscera in infancy and childhood have, for some
years weighed all the larger viscera in their autopsies and tabulated
their results. The conclusions they arrive at are as follows :

(i) The study of the average weights of the viscera in infants
and children, up to the age of five years, shows that there is constant
relation between the weights of the more important viscera, thus :

(a) The weight of the liver will average seven times that of the
heart.

(b) The weight of the spleen will average one-tenth that of the
liver.

(2) That the weight of the thymus gland as commonly given is
excessive, owing to the acceptance of pathologic glands as the stan-
dard for normal conditions.

(3) That the average weight of the thymus at autopsy is approx-
imately 6.0 grams.

(4) That there is no evidence of a growth of the thymus after
birth under ordinary conditions, but that under special conditions the
gland does grow and even hyx)ertrophy enormously.

506 ORIGINAL ABSTRACTS.

ETIOLOGY AND DIETETIC TREATMENT OF INFANTILE

ATROPHY.

Wentvvorth says (Jama, August 26, 1905) it is generally believed
that infantile atrophy is usually produced by a combination of errors
in feeding, though the way faulty feeding leads to it is unknown.
Nothnagel and Baginsky believe a constant derangement of digestion
causes atrophy of the intestines. Heubner and Block dispute this
theory and believe that the only change is that in Paneth's trells
in Lieberkuhn's ducts these cells do not contain the granules which
are supposed to be evidence of their functional activity. The strongest
evidence against the intestinal atrophy theory is the rapidity of
improvement when the infant is given a suitable food. Probably
impaired intestinal functions are of chief importance! in produc-
ing the atrophic condition. The chronic intoxication theory is not
proved. The feeding with breast milk restores the function very
quickly, and possibly there are some ferments present in human
breast milk which stimulate digestion. As regards feeding, three
courts are open : Proprietary foods, cow's milk mixtures, and human
breast milk. The first are generally unsuitable and are often the cause
of rickets and scurvy. Cow's milk mixtures are better; they should
be given regularly and at frequent intervals, but they too, are usually
unsuitable. The human breast milk is by far the most reliable in the
author's experience and the improvement is often so marked that
even a temporary change to breast milk will enable the infant to
regain enough digestive power to allow it to thrive on a cow's milk
mixture.

OTOLOGY.

R. BISHOP CANFIELD, A. B.. M. D.

rROPSaSOR op otolaryngology in THB UNIVBRSITY of MICHIGAN.
AND

MARSHALL LAWRENCE CUSHMAN, M. D.

DBMONSTRATDR OV OTOLARYNGOLOGY IN THB UNIVBRSITT OP MICHIGAN.

TREATMENT OF ACUTE PURULENT OTITIS MEDIA
AND MASTOIDITIS WITH BIER'S HYPEREMIA.

KoPETZKY, of New York City, in the Archives of Otology, Vol-
ume XXXV, Number IV, reviews the history, case reports, and
technic of this therapeutic agent and discusses several of his own
cases, with the following conclusions :

(i) If used early it will greatly increase the probabilities of cur-
ing the condition without resort to major operative measures.

(2) In cases cured under its influence the reestablishment of ear
function will occur quicker than under the usual line of treatment.

(3) Its use by the inexperienced is absolutely dangerous.

(4) Its employment should be limited to the young and the other-
wise healthy.

INFERIOR RETROPHARYNGEAL ABSCESS. 507

(5) Finally we submit that when the indications are kept in mind
and when properly and intelligently used, induced h)rpercmia will be
found a measure destined, when its scope and limitations are better
understood, to find a permanent place in otologic therapeutics.

M.» L* C*

ETIOLOGY, DIAGNOSIS, AND TREATMENT OF AURICU-
LAR CHONDRITIS AND PERICHONDRITIS.

Deuchfield, in The Laryngoscope, Volume XVI, Number VIII,
states that aside from the so-called idiopathic cases as seen in the
insane, this condition is almost always due to trauma, and ques-
tions with Kirksbride and Cumen that even in the insane, were the
truth but known, the etiologic factor is some punitive or self-inflicted
blow and not a lesion of the restiform bodies as stated by Brown-
Sequard.

The diagnosis may be made from the history of trauma and the
appearance of the auricle, erysipelas, frost-bites, and new growths
easily being differentiated.

The endeavor should be, first, to secure absorption by means of
heat, cold, iodin or ichthyol and these failing, incision into the lower
border of the mass with drainage of its ^contents and application of
pure carbolic acid followed by absolute alcohol, should be made.

M. L. c.

LARYNGOLOGY.

WILLIS SIDNEY ANDERSON, M. D.

CLINICAL PROFBSSOR OF LARYNGOLOGY IN THB DETROIT COLLEGE OP MEDICINE.

INFERIOR RETROPHARYNGEAL ABSCESS, FOLLOWING
THE REMOVAL OF ADENOIDS IN AN ADULT.

Doctor Aka (Reime Hebdomadaire de Laryngologie, D'Otologie,
et de Rhinologie, September 22, 1906) reviews first the complications
which may follow the removal of adenoids, and then gives the history
of a very interesting and unusual case of retropharyngeal abscess.

The patient was a woman, aged twenty-six years, who was operated
upon for adenoids. All the usual aseptic precautions were taken, and
nothing unusual occurred at the time of the operation. Fourteen days
after the operation the patient returned with the history of gradually
increasing difficulty of swallowing and evidences of septic infection.
Examination showed nothing unusual in the nasopharynx, with the soft
palate, or with the, posterior pharyngeal wall. On depressing the
tongue firmly a swelling, of the lower portion of the pharyngeal wall
could be detected, which hid from view the arytenoid cartilages and
completely blocked the opening into the esophagus. A diagnosis of
abscess of the lower portion of the pharyngeal wall was made, and it

506 ORIGINAL ABSTRACTS.

was opened by the galvanocautery knife. Considerable pus was evacu*
ated, the cavity was washed out and a cure resulted.

The author does not believe that the infection resulted from any
faulty operative technique, but rather that the chronic inflammation of
the nasopharynx furnished the germs for the acute infection. The
operation allowed the germs to enter the lymphatics, or the veins of the
pharyngeal wall.

Prompt evacuation of the pus from an abscess in the lower portion
of the phar)mgeal wall is imperative, as infection of the posterior medi-
astinum may readily take place. Such an infection is serious because
of the difficulty in draining an abscess of the mediastinum.

REPORT OF A CASE OF POLYPOID LIPOMA OF THE
• TONGUE.

Adolph O. Pfingst (The Laryngoscope, September, 1906) reports
a very unusual case in a girl, aged fourteen years. The growth was
first noticed by the mother when the patient was about three weeks old,
and had been allowed to grow gradually larger.

The growth was attached to the tongfue at a point corresponding to
the foramen cecum, and consisted of a large pedunculated mass of a
peculiar shape which could be aptly compared to a fetal chicken or
duck. It had a smooth though slightly irregfular surface, was pink in
color, and rather firm to the touch. . Serious difficulty in speaking, swal-
lowing, and breathing resulted from the presence of the timior. The
growth was removed with a Peters' snare. The hemorrhage was pro-
fuse for a few minutes, but subsided prcMnptly. The patient made a
good recovery. There was a marked tendency on the part of the patient
to sleep after the operation, and there was a noticeable improvement in
the voice and general health.

The tumor immediately after the operation weighed just one-half
ounce. It was two and one-fourth inches long, one and one-fourth
inches across its broadest part, and one-half inch at its apex. Its pedicle
measured three-fourths of an inch. Microscopic examination proved
it to be a lipoma.

The author reviews the literature of the subject.

THE BACTERIA IN SCARLATINAL AND NORMAL

THROATS.
GusTAV F. RuEDiGER (/(WUJ, Octobcr 13, 1906) quotes a number of
observers on the subject, gives his method of study, and the results
from a study of one hundred fifty-four throat cultures. His conclusions
are:

The streptococcus pyogenes is constantly found in great abundance
on the tonsils of patients suffering from tonsillitis and scarlet fever

PERSISTENT UNILATERAL HEADACHE. 509

before the inflammation of the throat has subsided. These organisms
rapidly decrease in numbers with the subsidence of the throat symptoms.

The streptococcus pyogenes cannot be considered a normal inhab-
itant of all healthy throats, although it was found in small numbers in
fifty-eight per cent of the normal throats in this series.

Pneumococci of low virulence was found in one hundred thirty-five
of this series of one hundred fifty-four throats.

-4 large group of organisms which lie between the typical strepto-
coccus pyogenes and pneumococcus was found in normal throats and
in nearly all diseased throats. These organisms have very little viru-
lence for rabbits, and, as they are found in great abundance in nearly
all throats, they appear to be normal inhabitants of the throat.

The streptococcus pyogenes from normal throats appears to have
a slightly greater virulence for rabbits than these organisms from
scarlatinal throats.

PERSISTENT UNILATERAL HEADACHE DUE TO NEVOID

CHANGES IN THE ANTERIOR EXTREMITY OF

THE MIDDLE TURBINAL BONE.

Wyatt Wingrave (Journal of Laryngology, Rhinology and Otol-
ogy, August, 1906) cites an interesting case in a man, aged thirty-eight,
who had a severe and persistent frontal pain of three months' duration,
dating from a severe attack of influenza. He had frequent attacks of
coryza, which generally aflForded partial relief. The right nostril was
found to be free, but the left was obstructed, in part, by a slight septal
deviation, but mainly by hypertrophy of the middle turbinal, which
completely blocked the meatus. The sinuses were found to be clear on
transillumination.

Local sedatives, general depletion, and bromides for a week afford-
ing no relief, the anterior end of the middle turbinal was removed b^
means of a Krause's fine wire snare. Complete cure with the relief of
the pain.

On microscopic examination of the specimen the mucous membrane
appeared normal, but the bony cancelli were found to contain very thin
vessels distended with blood and pressing on the walls. There was no
evidence of lymphocyte infiltration, nor any osteoplastic activity such
as is usually found in inflammatory sinusitis involving the bone. The
morbid condition may be regarded as a passing nevoid state of the
spongy bone, possessing no semblance whatever to any inflammatory
process such as rarefying osteitis, necrosing ethmoiditis, suppurative
sinusitis, et cetera.

The author very properly advises against the use of the cautery in
these cases, and favors the removal of the anterior end of the middle
turbinal. A strong and fine wire should be used, and if pushed upwards
and backwards will readily engage and* rapidly cut through both bone
and mucous membrane.

510

cumcAL nowmatom.

ORIGINAL ABSTRACTS.

PROCTOLOGY.

LOUIS JACOB HIRSCHMAN, M. D.

OP PBOCTOLOGT IN TMB OBTBOXT COLLBCB OP

STERILE WATER ANESTHESIA IN OPERATIVE TREAT-
MENT OF DISEASES OF RECTUM AND ANUS.

Gant, in a paper with the above title, read before the New York
Academy of Medicine, and published in the New York State Journal
of Medicine, Volume VI, Number X, summarizes the statistics and
views of the leading proctologists of the country as to their experience
with this form of anesthesia. He has collated eight hundred seventy-
nine cases up to May i, 1906, as follows:

Operation.

NUMBER

OF CASES.

NUMBER OF FAn.URES TO
GET SATISFACTORY
ANESTHESIA.

L. T. iCraiise. Cincinnati

19
63
71

10
18
74
59
71
25
129
20

320
879

One failure in a fissure case.

T Chittenden Hill. Boston

F. W. Stevens, Bridgeport,
S. T. Earle. Baltimore

Connecticut .

A few cases but not very

satisfactory.
One case of shock.

G. B. Evans. Dayton

J. £. Jelks, Memphis, Tennessee

A. B. Cooke, Nashville, Tennessee

L. J. Hirschman, Detroit

Three failures.
Six felt some pain.

W. M. Beach. Pittsbursh

C. S Gilman. Boston

One failure.

W. L. Dickinson. Satrinaw

J. P. Tuttle, New York

Only partially successful in
17, but well satisfied.

Failure in 27 cases, some
pain in 35 cases.

J. R. Penntnffton. Chicago

S. G. Gant, New York

J. M. Mathews, Louisville . . -

Total

Almost without exception, the above men are entirely satisfied with
this method, and some state that the anesthesia is fully as satisfactory
as that produced by chemical means.

DERMATOLOGY.

WILLIAM FLEMING BREAKEY. M. D.

CLINICAL PROFBSSOK OP DBKMATOLOGY AND STPHILOLOGY IN THB UNIVBftSITY OP MICHIGAN.

AND

JAMES FLEMING BREAKEY, M. D.

ASSISTANT IN DERMATOLOGY IN THB UNIVBRSITY OP MICHIGAN.

EXPERIMENTAL STUDY OF SOME CASES OF URTICARIA.
This article, by Erasmus Paramore, in the British Journal of Der-
matology, Volume XVIII, Numbers VII and VIII, is founded upon
the suggestion of Wright that urticaria is of the nature of a serous
hemorrhage associated with a defective blood coagulability and due to
a diminution of calcium salts in the blood content.

EXPERIMENTAL STUDY OF URTICARIA. 511

Wright's methods of estimation of the lime salts in the blood con-
tent and their relation to coagulability are given.

A short series of cases are reported with a study of the lime con-
tent and coagulation time and the results of shortening the coagula-
tion time by the administration of calcium chlorid. Some of the
patients experienced almost immediate relief under the treatment and
were permanently relieved by its continuation. Others were improved
and recurred or remained unchanged. In one of these an attempt
was made, by the administration of citric acid, to prolong the coagu-
lation time (also to secure an increased action of the kidneys) in order
to wash out, as it were, any noxious substances that conceivably lay
concealed in the subcutaneous tissues and which by their continued
presence served to maintain a condition of inflammatory irritability
and hence an increased transudation of plasma. Citric acid was admin-
istered in dram doses, thrice daily, for six days. Under normal cir-
cumstances this dosage should have reduced the lime content by one
half. For constipation the patient took mixture alba one ounce,
and four hours later the lime content had doubled, being four times
the expected amount. It was found in this case that an urticaria slight
in intensity and of a papular character, was by the exhibition of a
decalcifying agent replaced by an urticaria of some considerable
intensity, the lesions appearing in the form of wheals all over the
body. On the restoration of the previous lime content the papular
t>'pe was again reproduced with corresponding alleviation of symptoms.

In two cases, efforts were made to produce urticaria by a rapid
decalcification of the blood with oxalic acid in ten-grain doses. In the
first (the author) severe itching developed all over the body within
two or three days, worse at night. In the other case no symptoms
developed. In these two cases, though there was a considerable dimi-
nution in lime salts in the blood content there was no prolongation of
the coagulation time. "In consequence an urticaria of this type can-
not be held to be a serous hemorrhage dependent on a diminished lime
content. An urticaria produced under such conditions must bear a
similar relation to a decalcification urticaria that an active inflammation
bears to a passive exudation. In other words we have to consider a
toxic or inflammatory urticaria."

After reviewing the early cases Paramore says: "It seems, there-
fore, permissible to consider that an attack of urticaria may be due to
a diminution in the content of the blood in lime salts associated in con-
sequence with defective blood coagulability — ^that is to say, is of the
nature of a serous hemorrhage, a decalcification urticaria. That such
a condition of blood does not in the majority of cases mean urticaria
is more easy of proof. That an urticaria should develop in one man
while no such manifestation is apparent in another exposed to the same
conditions may quite well depend upon the ease with which toxic and
decalcifying substances are excreted by their respective kidneys.''

An urticaria the result of insect bites, nettles, et cetera, is neces-

512 ORIGINAL ABSTRACTS.

sarily local ; limited by the area in contact. Such a condition cannot
be considered as a modification of the blood as a whole, a local alter-
ation must be sought in the tissues in the immediate neighborhood,
this is found in the effects of the toxine upon local lymph ^aces.

In conclusion, urticaria may, then, in consideration of the altered
relationship of the chemical constituents of the blood, be divided into
three main groups :

(i) Decalcification urticaria.

(2) Urticarias due to an alteration of the salt content of the blood.

(3) Inflammatory or toxic urticarias, general and local.

J. F. B.

RADIOLOGY.

VERNON JUSTIN WILLEY. M. A.

STRVCTOR IN BLBCTROTHBRAPBUTICS IN THB UNIVRKtITT OP MICHIGAN AND DIRBCTOR 09 TMB

umvBBsrrr HoiiprrAL kobntcbn labobatobv.

NOTE ON THE USE OF THE MILLIAMPERfiMETER IN
ROENTGEN RAY MEASUREMENT.

. Jones (Archives of the Roentgen Ray, Volume XI, Number I)
presents this review of our present position in the measurement of the
volume of Roentgen rays so far as the use of the milliamperemeter in
the tube circuit is concerned.

The author first states that no one who has used a milliampere-
meter (in connection with the Villard valve) for regular work will
doubt the value of that method as an index of the working of the
Roentgen tube. Yet many practical workers doubt its reliability as a
method of precision. He also calls attention to the fact that an instru-
ment, which will indicate the volume or quantity of rays by the simple
movement of a pointer on a scale is much to be desired. He states that
the following questions must be settled before the milliamperemeter
can be accepted as reliable for Roentgen ray volumetric measurement.

(i) Does Roentgen ray production bear a direct relationship to
the magnitude of the current through the tube?

(2) What difference may be expected to exist between the amount
of Roentgen ray production within the tube and the amount available
for use outside?

(3) Can the milliamperemeter be trusted to give a measure of that
part of the current through the tube which is concerned in the produc-
tion of Roentgen rays, and of that part only?

(4) How may the readings be interpreted to suit different distances
of the radiant point from the surface irradiated?

In his answers to these questions the author concludes:
First, that a high hard tube gives out more jr-rays than a lower
one, the current measurement being the same through both tubes.

TREATMENT OF TRIGEMINAL NEURALGIA. 513

Second, that the milliamperemeter fails to take any account of the
rays absorbed by the walU of the tube, and in that instance is not as
reliable for measuring the volume of rays delivered outside the tube
as are the pastilles of Holzknecht, or the pastilles of Sabouraud and
Noire. In very soft tubes a large percentage of rays are absorbed by
the glass, as has been shown by the experiments of W. Seitz, using a
tube with an aluminium window, through which soft rays readily pass.

The third question can be answered affirmatively only for tubes of
equal Roentgen ray efficiency.

The answer to the fourth question involves the measurement of the
distance from anode to skin or photographic plate and a comparison
with some other method of measurement such as either a photo-
graphic method or the use of the Holzknecht pastille. v. j. w.

NEUROLOGY.

DAVID INGLIS, M. D.

PKOFBSSOR or NBRVOUS AND MBNTAL DISBASBS IN THB DBTROIT COLLBCB OP MBDICINB

AND

IRWIN HOFFMAN NEFF, M. D.

ASSISTANT PHYSICIAN AT THB BASTBRN MICHIGAN ASYLUM.

'*THE SURGICAL TREATMENT OF TRIGEMINAL
NEURALGIA."

MoscHCOwiTZ thoroughly reviews {Medical Record, September,
1906) the operative treatment of trigeminal neuralgia, considering
the advisability of the different surgical methods which have been in
use. The article is critical, but comprehensive and instructive. A
description of the author's work in this respect is given, and the
writer makes the following conclusions :

. (i) Eliminate any possible etiologic factors, such as tumors,
carious teeth, antral disease, malaria, syphilis, et cetera.

(2) Determine accurately the nerve branch or branches
involved.

(3) The operation should be performed as near to the perijrfiery
as possible.

(4) The operation should be performed early. This is important,
because the earlier the case, the more chances there are that a per-
ipheral operation will be of benefit.

(5) Whatever the character of the operation may be, the dom-
inant principle must be the prevention of regeneration of the affected
nerve. More specifically, the operations may be classed under two
headings, depending on the nerve or nerves affected :

(a) Peripheral operations. — If the supraorbital, infraorbital, men-
tal, malar, or inferior dental branches, either singly or collectively
are involved, the operation consists in division of the nerve, and plug-
ging up of the foramen by a gold or silver button or wire.

614 ORIGINAL ABSTRACTS.

(b) Central operations. — If the neuralgia involves the upper teeth
and palate (superior maxillary division) or tongue (inferior maxil-
lary division), existing either singly or together wth the other nerves
described above, the operation as outlined by Abbie must always be
performed, substituting, however, celluloid or a gold button instead
of rubber tissue.

(6) Finally, I believe that if the above principles of treatment of
trigeminal neuralgia are carried out, the operation of extirpation of
the Gasserian ganglion will become entirely unnecessary.

L H. N.

"THE CEREBRO-SPINAL FLUID IN HEALTH AND
DISEASE."

Archambault has reviewed (Albany Medical Annals, May, June,
July, 1906) all literature to date on this subject, and has appended
a valuable and complete bibliography. The article is well written and
affords a ready and reliable reference to this important clinical pro-
cedure. As the article is written in the nature of a review a summary
is impossible. i. h. n.

THERAPEUTICS.

DELOS LEONARD PARKER, Ph. B., M. D.

LBCTURBK ON MATSRIA MSDICA IN THS DBTROIT COLLBCB OP MBDICINB.

PROGRESS IN SERUM THERAPY DURING THE YEAR
ENDING JUNE i, 1906.

Doctor Ezra Read Larned, of Chicago, in the September number
of the Therapeutic Gazette, presents a general review of the standing
and position of the different curative sera that is interesting and
instructive, especially to the general practitioner.

At the outset the statement is made that no matter how great the
value of a remedy may be made to appear by test-tube reactions, or the
results of experiments applied to animals, it is only when the agent
accomplishes what is expected of it by the doctor at the bedside that its
reputation is fully established.

Doctor Lamed classifies curative sera as follows :
(I) All whose efficacy have been proven.
(II) Those whose value is not definitely proven.

(Ill) Those proven worthless for clinical purposes.

A year ago in a paper which was reviewed in these columns, Doctor
Lamed included in Class I antidiphtheric, antitetanic, antistreptococcic,
and antiplague sera. In the present paper he says he is not able to
extend this list. He says that much information has been gained
concerning these and other sera during the past year, but that the list
as presented in the former paper is not lengthened by such information.

DISINFECTING POSSIBILITIES. 515

In Class II, he places antithyroidin, thyroidectin, serum for exoph-
thalmic goitre, hay fever, serum, tuberculin, antianthrax serum, and
serum for relapsing fever.

In Class III (sera valueless thus far for therapeutic purposes)
there are found antipneumococcic, antidysenteric, antityphoid, antivari-
oloid, anticancer, antiei^ysipelas, antirabic, antimalarial, antirheumatic,
antisyphilitic, and antigonorrheal sera, and leprolin.

During the past year notable efforts have been made to develop sera
applicable to the treating of exophthalmic goitre, gonorrhea, and
syphilis. Success, however, has not yet attended these efforts.

Of ideal specific sera antidiphtheric serum is easily first. Among
its points of merit are the following : It is harmless, its use is not beset
with contraindications, it protects as well as relieves, and is always
efficacious if administered early and in sufficient quantity.

Antitetanic serum both for immunizing and curative purposes,
Doctor Larned thinks, is as capable of producing as good results as
antidiphtheric serum. But owing to the fact that much has yet to be
learned about tetanus, especially by the general practitioner, and also
that the dosage of the remedy is still unsettled, we are not able to get
from this serum all the benefits it is capable of yielding.'

Antistreptococcic serum can be counted on to give good results in
all cases of single infection. In all cases in which the agent is used
properly, but with indifferent results, it is altogether probable that the
sepsis is caused by a mixed infection, other organisms acting with the
streptococci.

Antiplague serum in large and frequently repeated doses is of
positive value. This agent, and the effects it may produce, is of great
importance to the physicians of the United States because of the large
number of soldiers and travelers continually coming to this country
from the east, the home of plague.

Hay fever serum as a therapeutic agent is still under judgment,
but Doctor Lamed thinks its standing will soon be determined.

EDITORIAL COMMENT.

DISINFECTING POSSIBILITIES OF BACTERIA PECULIAR
TO THE INTESTINAL TRACT.

That the intestinal bacteria are essential to the physiologic
economy of the human organism has long been determined, and that
they functionate as scavengers and destroyers of pathogenic germs that
gain access to the enteron is a theory generally accepted. The intro-
duction into the intestines of germicidal and antiseptic agents for the
disinfection of the tract results not only in the destruction of the patho-
genic invader, but likewise effects the extermination of the natural
intestinal flora and bacteria.

616 EDITORIAL COMMENT.

How, then, can an aseptic condition of the intestinal canal be
gained without deleteriously affecting physiolc^c function? Moro
discussed this question at the recent Congress of German Natu-
ralists and Physicians. He contended that the best method of
remedying a pathogenic condition of the intestines was the infusion
of the natural nonpathogenic organisms, or the creation of a con-
dition wherein their growth was best facilitated. Administration of
cultures per orem was not recommended, but the injection of agar
cultures of bacillus coli, bifidus and other organisms peculiar to the
tract per rectum was advised. The colon bacillus is known to retard
the growth of both typhoid and dysentery bacilli, and if human milk
be injected into the intestinal canal as a medium, practical demon-
stration has disclosed the fact that bacillus biiid\is inhibits the develop-
ment not only of pathogenic bacteria but also of the normal intestinal
organisms. While the development of one intestinal organism to the
exclusion of others cannot be commended in the normal economy,
still, recourse to the discovery in disease conditions would undoubtedly
prove advantageous. Plain milk of the bovine variety is an excellent
culture medium for most species of bacteria, but probability obtains
that some constituent in the human lacteal fluid is responsible for the
ready growth of bacillus bifidus, and the isolation of this product will
throw much light on the subject of intestinal disinfection.

ANNOTATIONS.

A NEW TRYPANOSOME PECULIAR TO TROPICAL AFRICA.
The latest contribution to the field of bacteriology is that of Broden
who describes a new trypanosome peculiar to the Congo region. The
organism is small — ^ten to sixteen and five-tenths by one to two microns.
It is almost devoid of undulatory membrane, motility being facilitated
by wave-like movements of the protoplasmic body. Staining discloses
the characteristics of the known varieties of trypanosomes — protoplas-
mic body, nucleus, c^ntrosome, flagellum, and a very slight undulatory
membrane, in which later structure it differs from the other types.
The centrosome is situate at the posterior -extremity of the parasite
and invariably against one of the body walls. The flagellum is not
free in any part, terminating in the protoplasmic body. The new
trypanosome is pathogenic to rats, guinea pigs and goats, in which
it induces an acute infection, and to sheep and certain species of
monkey, which are chronically affected. The symptoms are hypertrophy
of the lymph nodes, and, in animals of high resistance, hypertrophy of
the spleen. An organism simulating the new discovery has been
isolated from the blood of dromedaries, and since the lesions produced
from infection with either bear strong resemblance the discoverer con-
siders the organisms practically identical.

ACTION OF BREWED TEA. 617

LEAD COLIC RESULTANT FROM CARBONIZED WATER.

Baldwin "records two cases of lead poisoning incident to the con-
sumption of water drawn through lead mains. The community in
which the cases occurred suffered from quite a severe epidemic of the
disorder, and investigation disclosed the fact that contamination was
due to the presence in the water of carbonic acid, which attacked the
pipes. The disorder may occur in any locality where lead' pipes are
employed, and may persist or subside according to the presence or
absence of the acid product in water. Waters which issue from the
depths of the earth contain more carbonic acid than do surface waters,
but the inconstancy of parity is apparent from the fact that the pres-
ence of the acid varies in the same water.

A NOVEL METHOD OF REDUCING INFANT MORTALITY.

An ingenious but apparently effective method of reducing infant
mortality has been devised in England. Upon the accession of Alder-
man Broadbent, brother of the King's physician, to the mayoralty of
Huddersfield, he offered a guinea to the parents of children born within
a certain district during the twelve months of his term and living at its
expiration. For ten years the infant mortality of the precinct had been
one hundred twenty-two to every one thousand. At the termination
of the period of award the records disclosed a diminution of the death-
rate from one hundred twenty-two to forty-four per one thousand.
The significance of these figures is referred to the reader for solution.

DECREES AFFECTING NASAL DEFORMITY.

Indemnity for damage to the nose is accorded different estimation
in different countries." Occupation, sex, and motive of the malefactor,
if malice enter into the case, have much to do with the amount of the
award. A young English woman who sustained a broken nose was
recently granted a verdict of five hundred pounds, while an electrical
engineer received only fifteen pounds. In France the nasal adornment
is less highly valued. A man whose nose came in contact with the fist
of an enemy received only eight hundred francs, the courts, however,
awarding a young woman, an artist's model, three thousand francs for
a slight nasal injury sustained in an omnibus accident. The equity of
the latter judgment is apparent.

BACTERICIDAL ACTION OF PROPERLY BREWED TEA.

McNaught, an English army surgeon, has made some interesting
observations bearing on the bactericidal action of tea, with especial
reference to the bacillus typhosus. The organism, in pure culture,
becomes greatly attenuated after four hours exposure of the beverage,
twenty hours being sufficient for its complete destruction. From a

618 EDITORIAL COMMENT.

military standpoint the discovery is certainly fraught with great sig-
nificance, since the substitution of properly brewed tea for water would
tend to dissipate the possibility of typhoidal infection of army camps
and stations. The employment of sterilized water in soldiers' canteens
is indeed commendable, but infection after sterilization is no uncom-
mon occurrence, and the finding of a bactericidal fluid possessing all
the attributes of water is worthy of consideration as a prophylactic
against typhoid.

CONTEMPORARY.

HYPNOTISM: ITS HISTORY, NATURE, AND USE.

[KAMOLD M. MATi, or TMB COLLBGB OP riCTSIClAllS AMD SUHGBONS, MXW TOKK CtTV, tM THB POPULAK

SCIBNCB MONTHLY.]

( Cantintud/ram p^tge /»)

THE NATURE OF HYPNOTISM.

Each individual has a separate state of consciousness which changes
as do the thoughts therein. It is in the waking state that we have
separate individualities. Now let us see the gradations of this con-
sciousness. At this present moment we shall say we are listening
intently to a sermon. That is the thing uppermost in our minds, and
as long as our minds are upon it we are exercising acute consciousness.
But, even if our attention to this sermon is the central thing, in the
fringe of our mental picture a number of other thoughts are jtunping
around, any one of which may be powerful enough to force its way into
the middle of the picture and to usurp its place. For example, all the
while we are listening to this sermon we are more or less conscious
that the seats we are in are hard, that somebody is talking next to us,
et cetera. Our seats may become so unccwnfortable that it may occupy
our whole attention, or something outside may seem of more interest
If our attention jumps from one thing to another, it is called diffused
consciousness. The next step to diffused consciousness is the dreamy
state where the mind is half way between waking and sleep. Anything
may come into the mind while in this state and be the predominant
idea, to be chased out again by a next idea. It is for this reason that
dreams usually present such a chaos and jumble. Our thoughts tumble
over one another to get from the fringe of consciousness to the fore-
ground. Any external sensation will be greatly exaggerated and may
turn the trend of our thought. A warm bed might feel like the fire of
hell, a heavy dinner with indigestion like the battles of heroes using
our poor bodies as the fighting ground. As dreams gradually fade
away we approach our first hypnosis or sleep, which, in the beginning,
is slight, bi!t gradually deepens, finally consciousness being entirely lost

Thus we have traced the process of natural sleep to which hypnotic
sleep is closely akin. The person at first has a diffused attention, he

HYPNOTISM. 619

then confines his attention to sleep, he next passes into a dreaming state,
then into .a light sleep, and lastly into a deep sleep.

The differences between it and natural sleep are as follows: first,
the state ordinarily is produced by another; secondly, the person must
have faith ; and thirdly, the phenomena in the sleep must be produced
by suggestion. The two latter were fully recognized years ago and
have formed the basis of all psychical cures ever since. How the sleep
can be produced by another was seen in the experiments of Braid,
where one appreciates fully that the person really hypnotizes himself
by gazing at an object. The full understanding between hypnotized
and hypnotist has never been really understood, and so here we are
stopped short.

The theory of Doctor Hudson may put us on the right track.
Because it is so convenient a theory and tends to make plausible a
number of things which otherwise could not be understood, I am going
to take the liberty of detailing it here. Doctor Hudson claims that every
normal person is possessed of two minds, a subjective one and an
objective one. The objective mind is the one we use every day, a mind
fully capable of forgetting and the only one of which we are ordinarily
cognizant. The subjective mind is the perfect mind wherein are stored
up all the numerous thoughts that have ever come into it, there lying
dormant, only to be reawakened when a new set of associations brings
them forth.

It is this mind which we may say is used in hypnotism, in somnam-
bulism, the one which shows itself in altered personality and in various
other abnormalities. Some authors consider this the subliminal or
subconscious mind.*

That there is another mind far more perfect and which brings to
our recollection many things forgotten, seems to be an undisputed fact.
When a drug like cannabis indica is used or when a person is drown-
ing, there come before his mind's eye, in a single moment, the doings of
years. And so in some recorded cases of trance states the same thing
is proved. A highly interesting case is given by MV. Coleridge in his
"Biographica Literaria."

Mr. Coleridge says :

"It occurred in a Roman Catholic town in Germany, a year or two
before my arrival at Gottingen, and had not then ceased to be a frequent
subject of conversation. A young woman of four or five and twenty,
who could neither read nor write, was seized with a nervous fever,
during which, according to the asservations of all the priests and
monks of the neighborhood, she became possessed, and as it appeared,
by a very learned devil. She continued incessantly talking Latin, Greek
and Hebrew, in very pompous tones, and with a most distinct enuncia-
tion. This possession was rendered more probable by the known fact

*One cannot help realizing that this theory will never be fully accepted. Most
psychologists are still quarreling over concepts, and no two will agree as to what is meant
by a subjective or an objective mind.

520 EDITORIAL COMMENT.

that she was, or had been, a heretic. The case had attracted the par-
ticular attention of a young physician, and by his statement, many
eminent physiologists and psychologists visited the town and cross-
examined the case on the spot. Sheets full of her ravings were taken
down from her own mouth and were found to consist of sentences,
coherent and intelligible each for itself, but with little or no connection
with each other. Of the Hebrew, a small portion only could be traced
to the Bible ; the remainder seemed to be in Rabbinical dialect. All
trick or conspiracy was out of the question. Not only had the young
woman been a harmless simple creature, but she was evidently under
a nervous fever. In the town in which she had been resident for many
years as a servant in different families, no solution presented itself. The
young physician, however, determined to trace her past life, step by
step; for the patient herself was incapable of returning a rational
answer. He at length succeeded in discovering the place where her
parents had lived, traveled thither, found them both dead, but an uncle
surviving, and from him learned that the patient had been charitably
taken by an old Protestant pastor at nine years old, and had remained
with him some years, even till the old man's death. Of this pastor the
uncle knew nothing, but that he was a very good man. With great
difficulty, and after much search, our young medical philosopher dis-
covered a niece of the pastor's who had lived with him as housekeeper
and had inherited his effects. She remembered the girl; related that
her venerable uncle had been too indulgent, and could not hear the girl
scolded; that she was willing to have kept her, but that, after her
parent's death, the girl herself refused to stay. Anxious inquiries were
then, of course, made concerning the pastor's habits ; and the solution
of the phenomenon was soon obtained. For it appeared that it had
been the old man's custom for years to walk up and down a passage
of his house into which the kitchen door opened, and to read to himself,
with a loud voice, out of his favorite books. A considerable number
of these were still in the niece's possession. She added that he was a
very learned man and a great Hebraist. Among the books was found
a collection of Rabbinical writings, together with several of the Greek
and Latin fathers ; and the physician succeeded in identifying so many
passages with those taken down at the young woman's bedside that no
doubt could remain in any rational mind concerning the true origin of
the impression made on her nervous system."

The same power of the subjective mind is many times seen in
hypnotic phenomena. The case cited is but one of a number, all of
which are just as wonderful. Being a mind so perfectly endowed, it is
hardly too audacious to say that this mind exercises its influence over
all bodily functions, so that any function may be inhibited or accelerated
by its influence. For example, the following is related of Henry Qay.

"On one occasion he was unexpectedly called upon tcf answer an
opponent who addressed the Senate on a question in which Clay was
deeply interested. The latter felt too ill to reply at length. It seemed

HYPNOTISM. 621

imperative, however, that he should say something; and he exacted a
promise from a friend, who sat behind him, that he would stop him at
the end of ten minutes. Accordingly, at the expiration of the prescribed
time the friend gently pulled the skirts of Mr. Clay's coat. No attention
was paid to the hint, and after a brief time it was repeated a little more
imperatively. Still Clay paid no attention and it was again repeated.
Then a pin was brought into requisition; but Clay was by that time
thoroughly aroused, and was pouring forth a torrent of eloquence. The
pin was inserted deeper and deeper into the orator's leg without eliciting
any response, until his friend gave up in despair. Finally Mr. Qay
happened to glance at the clock and saw that he had been speaking two
hours ; whereupon he fell into his friend's arms, completely overcome
by exhaustion, upbraiding his friend severely for not stopping him at
the prescribed time."

The fact that Mr. Clay, on that occasion, made one of the ablest
speeches of his life, two hours in length, at a time when he felt almost
too ill to rise to his feet, and that his body was at the time in a condition
of perfect anesthesia, is a splendid illustration of the synchronous
action of the two minds, and also of the perfect control exercised by the
subjective mind over the functions and sensations of the body ("Law
of Psychic Phenomena").

I now propose to attempt to explain some of the phenomena of
hypnotism by reviewing thoroughly a specific example.

On November 23, 1901, I was asked by a young lady to try to cure
her of biting her finger nails. She was then about eighteen years of age.
'I immediately replied that I should be glad to do so if I had her full
permission. Besides her and myself, there were four or five other per-
sons in the room, including her father and mother. Getting her per-
fectly composed, I placed my hand on the top of her head, and told
her to turn her eyes in the direction of the hand. This tired her eyes
very readily. They became heavier, the eyelids twitched and inside of
five minutes they fell and she was sound asleep. I first placed her in
a cataleptic condition. I told her her arm was a piece of stone and
therefore could not be bent. Two or three of those assembled tried to
bend it, but failed. Then by more suggestion I placed her in an
anesthetic condition and rubbed the ball of her eye. She neither
winked nor flinched. I then gave her a few posthypnotic suggestions.
For example, I told her that when she awakened she would go over,
and close the window, that she would then thank me for what I had
done, and would feel no bad effects and also would remember nothing.*
Then I told her that the following Sunday I would come over, and, as
soon as I told her to go to sleep, she would do so. When she awoke,
she went over and closed the window, and then thanked me for what I
had done. She remembered nothing and felt much rested. Of course,
suggestions were constantly given that she would not bite her nails.

The following Sunday, I went over there again. She had not bitten
her finger nails since the last time I saw her. I told her to lie down and

522 MEDICAL NEWS.

that in three minutes she would be sound asleep. I used no method
whatsoever. In fact, I was in another room. When the three minutes
were up, I went in tb her and found her in a deep sleep. I impressed
on her a number of times that she would never bite her finger nails
again. I placed her in a chair, telling her to open her eyes. She wa$
to see or hear nobody but me. A number of people stood before her,
but she could not see them. I asked her a question which she readily
answered. Then somebody dse asked her the same question, but no
answer could be got from her. She seemed perfectly deaf to their
words. I asked her if she heard anybody else and she answered ''No.''
I next procured a needle which was perfectly clean, and telling her she
would feel no pain, I ran it into her forearm for over half an inch.
Very little blood appeared, as I had suggested, and she felt nothing.
In fact, after the experiments were over she did not know anything
about the wound. Taking a glass of water, I told her it was whiskey.
She took a little with some show of difficulty in swallowing, and when
I told her to walk about the room, she reeled around as though she
were overcome by the liquor. I then procured some salt, telling her it
was sugar and that it would cure her of her dizziness immediately. She
took the salt, a half teaspoonful, said it tasted sweet, asked for more;
and was entirely herself again. Finally I placed her between two
people, putting her head on one's lap and her feet on the other's. She
became cataleptic on my suggestion, and when two hundred and fifty
pounds were put on her body she sustained them very readily.

Before she awakened, I gave her three suggestions: (i) That as
soon as she awoke she would go into the front room and lie down on
the sofa for a few minutes; (2) that she would go up to her parents
and tell them that she was never going to bite her nails again; and (3)
that two weeks from that night she would sit down after supper and
write me a letter, thanking me for what I had done. All these sug-
gestions were carried into eflFect.

On Monday, December 9, two weeks and a day after the experiment
had been made, I received the following letter :

December 8th, 1901.
Dear Mr. Hays :

I feel as though I owe you a note of thanks for the wonderful cure
you have effected on me. I have not bitten my nails since three weeks
ago tonight and I am very proud of them. I am writing this to try to
let you know how much I thank you. It seems remarkable that a little
thing like hypnotism can do so much good, and I shall always feel grate-
ful and indebted to you for this. Yours sincerely, E.

Not until after the letter had been sent did she find out that it had
been I who prompted her to do it. This young lady has not bitten her
finger nails since and is entirely cured.

[to bb continuxd.]

MINOR INTELLIGENCE. 623

MEDICAL NEWS.

THE PREVENTION OF "PUTRIFACTION."

W. Jay Harrer, M. D., of Utica, New York, announces "a remedy
which is guaranteed to absolutely prevent intestinal 'putrifaction* "
in the human economy. He has issued a circular detailing how this
'putrifaction' "gives rise -to the formation of the deadly ptomaine
poisons, and that equally deadly poison, indican, the presence of which
in the human body not only induces arteriosclerosis and atrophy of the
tissues, but is accredited as the most powerful agent by which time
preys on we mortals." For the sum of five dollars this benefactor will
dispense complete working directions to any physician who will raise
his right hand and swear — "On my professional honor, I agree not to
divulge the same to any person or persons without first collecting and
remitting to you a fee of five dollars each, and placing them under
similar restrictions." The doctor is a graduate of the Baltimore
University School of Medicine, class of 1886. He is likewise a "Jay."

MINOR INTELLIGENCE.

The munificent gift of $200,000 was bequeathed to the Charity
Hospital of New Orleans, in the will of the late Mrs. Virginia McRae
Delgada of that city.

The founder of the Labrador Deep Sea Mission, Doctor Wilfrid
T. Grenfell, has been honored by King Edward VII with membersljip
in the Order of Saint Michael and Saint George.

SoMMERViLLE (Ncw Jersey) Hospital is the recipient of the sum of
$5,000 from Mr. S. S. Palmer, tendered in recognition of the faithful
care received by his wife after an automobile accident.

Because of ill health. Doctor Horatio C. Wood has resigned the
chair of materia medica, pharmacy, and therapeutics, in the University
of Pennsylvania. He has been elected emeritus professor.

At a recent meeting of the Yale corporation, announcement was
made that an anonymous benefactor had endowed a chair of medicine
in memory of the late Doctor John S. Ely, to the extent of $50,000.

By the will of the late Margaret Agnes Weiher, Saint Joseph's
Hospital for Consumptives, New York City, is the recipient of a
bequest of $1,000. Mrs. Weiher was the wife of Doctor Charles L.
Weiher, of that city.

The medical school of Pennsylvania University has a department
of experimental surgery, which was recently established under the
direction of Doctor J. E. Sweet, formerly connected with the laboratory
of hygiene at Rockefeller Institute.

524 MEDICAL NEWS.

Anthrax has appeared in Delaware, many animals having died
from the scourge. The carcasses of dead animals are burned in
accordance with the command of the state authorities, and all exposed
cattle are being inoculated.

By order of the health authorities of Maiden, Massachusetts, kiss-
ing games, as indulged in at children's parties, are henceforth to be
prohibited. The late prevalence of diphtheria in that city, which was
directly traceable to such amusement, instigated the mandate

An individual purporting to be the most diminutive person in
existence, died recently at Wilkesbarre, Pennsylvania. He was bom
in Wales, fifty-three years ago, and was but thirty-seven inches in
heighth, four inches shorter than the famous General Tom Thumb.

Gin Wai Chan^ a full-blooded celesti^il, was recently awarded
license to practice medicine in Illinois. Doctor Chan is a graduate of
the National Medical University of Chicago, class of 1906, and was
sent here by the Chinese government, whose idea it is to prepare him
for the chair of surgery in the Imperial University of Pekin.

The munificent fee of $33,000 for one hundred ten days' service
is the claim of a Philadelphia physician who recently commenced suit
against the estate of a wealthy resident of that city. His exclusive
services had been engaged by the individual, the stipulation being that
they travel together, the medical man to receive $300 per day.

The German Dermatologic Society will erect a suitable memorial
to the memory of the late Fritz Schaudinn, discoverer of the spiro-
chaeta pallida. Five thousand marks have already been subscribed to
the project. Besides the memorial the society will dedicate the first
volume of its transactions to the memory of the distinguished Teuton.

Twenty-nine thousand dollars have been appropriated for the
immediate reconstruction of the National Insane Asylum, at Havana.
Recent investigation disclosed a deplorable condition of affairs at that
institution. A better sanitary regime is also being demanded of propri-
etors of cafes and restaurants, many of whom are very lax in this
respect.

New York's new Jewish Hospital was formally opened on Novem-
ber 4, 1906. A three-story dwelling house on upper Madison avenue
has been completely remodelled and thoroughly equipped with modem
appliances. The institution is intended for the department of deformi-
ties and joint diseases, and is under the superintendency of Doctor
Henry W. Frauenthal.

After much opposition on the part of property owners, the Mc-
Cormick Memorial Hospital for children suffering from infectious
diseases, has at last secured a desired site on Fifty-fourth street,
Chicago. It is the intention of the promoter to erect a hospital thor-
oughly equipped in every way, on spacious grounds, and to carry on
charitable work on a large scale.

PRACTICE OF GYNECOLOGY. 525

Fire visited the new American Hospital and Training School for
Nurses at Constantinople, on the eve of its formal opening, completely
destroying the structures and equipment. The director in charge was
Doctor Charles Specs Carrington, of New York, and appearances
augured well for the success of the new venture, since occupants for
every bed in the wards were awaiting its opening.

Mrs. Catherine H. Polhemus^ of Brooklyn, widow of the well-
known philanthropist, in her will bequeaths over $500,000 to benevo-
lent purposes. The largest beneficiary is the Polhemus Medical Clinic
of Long Island College Hospital, which receives $250,000, in addition
to $50,000 for care of the building. The clinic is a memorial to her
husband, who died in 1895, and was established at an expenditure of
$400,000.

Announcement is made by E. G. Swift, General Manager of the
firm of Parke, Davis & Company, that on "J^^^^^^'y i> ^9^7> with The
Therapeutic Gazette — the oldest, strongest, most widely circulated of
our three medical journals — we will consolidate The Medical Age and
Medicine/* The new publication will be under the editorial control
of Doctors Hobart A. Hare, and Edward Martin, long associated in
the editorial conduct of The Therapeutic Gazette,

An unusual accident occurred recently in New York City, wherein
a trolley car collided with a Lebanon Hospital ambulance, precipitating
the occupants, two colored patients and the attendants, to the pave-
ment, the mishap subsequently resulting in the death of one of the
patients, who had been wounded in a shooting affray. The ambulance
surgeon, who was thrown a distance of fifteen feet, sustained severe
contusions and was unconscious for several hours.

The Berlin Tuberculosis Dispensary, established two years ago,
has lately issued a report announcing very favorable work accom-
plished during this period. Five hundred thousand marks have been
expended in the performance of its service; 15,661 persons were con-
sulted and examined, 18,644 visits being made to dwelling houses;
2,765 tuberculous patients were helped with their rent, while 804 were
consigned to hospitals; 1,000 persons were given homes in the woods
and other out-of-door places, and 8,200 dwellings were rendered
sanitary.

Doctor Jeremiah C. Wilson, of Rochester, Michigan, died in
that village on the 4th instant. He was one of the Wilson twins who
were widely known as partners in the practice of medicine for many
years. The surviving twin is Doctor Jesse E. Wilson, and another
surviving brother is Senator John Wilson, of Canada. Prior to form-
ing the twin partnership deceased practiced medicine two years in
Dryden. Failing health compelled him to retire from practice about
four years ago. At one time he was elected to the Presidency of
Rochester and in 1866 he was elected to the state legislature on the
Democratic ticket. A widow survives him.

526 RECENT LITERATURE.

Doctor Henry Tweedie, the father of medicine in Ireland, died
recently at the age of ninety-six, his demise resulting from a fracture
of the femur, sustained a few days before death. Doctor Tweedie
received his license to practice medicine from the College of Physicians
in 1836, and two years later was awarded his M. D. at Glasgow. He
leaves a son who is engaged in the practice of medicine.

RECENT LITERATURE.

REVIEWS.

A TEXT-BOOK OX THE PRACTICE OF GYNECOLOGY.*

That a second edition of any medical work should be called for
within six months speaks well for its popularity whatever may be said
of its worth. The author has clearly stated in his preface what he has
attempted to accomplish in his book and by that should his work be
judged. His aim has been to write a treatise on g>'necology in which
nothing is taken for granted. He will write and illustrate so that
any one can easily catch his meaning. He will set forth in detail many
things that the average physician knows or if he does not know would
assimilate if it were described once. All this will be done so that there
shall be no chance of obscurity about the work. Now, if we accept
the author's premises that there is need of a work of this description,
one is obliged to confess that he has been eminently successful. He
has given us a Readable, clear treatise. It is well illustrated, and what
is more to the point, the drawings are not used for padding purposes
but serve to make clear and illuminate the text. Can the same be said
of every author?

The opening chapters are given up to such general subjects as "the
general technic of g>'necologic examinations," "the blood in relation to
surgery," et cetera. Hydrotherapy and diet are dealt with very exten-
sively, much more than would seem to be called for in a book on gyne-
cology, yet the chapters are well written and place before the practi-
tioner valuable information. But it hardly can be called genecology.
To be sure it is extensively made use of in the treatment of diseases
peculiar to women, but so are many medicines ; yet one never thinks of
giving up a number of chapters to the general subject of therapeutics.

The adoption of the anatomic arrangement for the consideration
of the different gynecologic diseases commends itself alike to prac-
titioner, student, and teacher. Especially from the latter's standpoint
has the arrangement of text-books along the pathologic basis been a
failure. The student is confused and not aided by the successive
consideration of the changes resulting from a certain moAid process

NASAL SINUS SURGERY. 527

in various parts of the generative tract. The sense of incompleteness
resulting from such a plan more than counterbalances any good arising
from the consideration of the difTerent diseases in their etiologic
sequence. Also there is truth in the author's* statement that the
anatomic basis permits of a discussion of the various methods of
examination of each organ before its diseases are described. Such
methods, when grouped together in one chapter are very apt to lose
their significance.

The various diseases of the special organs are carefully and clearly
described. It is doubtful, however, whether anything is gained by the
method of depicting again and again the very same instrument used in
different operations. It would seem as if much valuable space had
been wasted in such repetitions, for after all the man who is able to
operate will make his own selection of instruments. Those who have
to be carried through each operation and not only have to have their
instruments selected for them but are obliged to have pictures made of
the same instruments again and again are hardly the men to be trusted
with the responsibilities of operating. They would do fc^r better work in
some other field. Space gained by omitting such repetitions could very
profitably have been spent ujJon descriptions of pathologic conditions,
for the sins of omission in this particular are very noticeable. It is too
true, perhaps, that in the past many books written for the student and
general practitioner have devoted too much space to microscopic path-
ology, but that is no reason for going to the other extreme and ignoring
the pathologic side of the problem entirely.

Yet withal, it is an interesting book and one worthy of careful
perusal. It has that refreshing quality of being free from the faults
of the mere compiler. It shows the marks of an independent worker
and writer, who has given us a well-written, clear, exposition of his
subject. He sets forth what he himself has seen. He leaves for others
the historic reviews and the summing up of the work of others.

R. p.

♦By William Easterly Ashton, M. D., LL. D. Second edition, 1906.
Published by W. B. Saunders Company, Philadelphia and New York.

NASAL SINUS SURGERY WITH OPERATIONS ON
NOSE AND THROAT.*

The author has given, in a concise and well arranged form, a
valuable guide to surgery of the nose and throat. Of the ten chap-
ters five are devoted to the surgery of the sinuses. In these chapters
the essentials of sinus surgery are given. The remainder of the work
is devoted largely to surgery of the septum, turbinals, tonsils and
adenoids. The concluding chapter deals very briefly with laryngot-
omy and tracheotomy. In a work of less than three hundred pages
we cannot expect the subject to be fully covered, but what Doctor

628 RECENT LITERATURE.

I>ouglass has done he has done well. It is to be regretted that such
a useful book could not have been made more complete. The text is
arranged under headings, which makes it very easy for reference.
The illustrations of dissections are numerous and clearly reproduced.
The author's large experience as a surgeon and teacher enables him to
give what is most useful to the average practitioner. We welcome the
book as a valuable addition to laryngologic literature. w. s. a.

♦By Beaman Douglass, M. D., Professor of Diseases of the Nose
and Throat in the New York Post-Graduate Medical School and
Hospital. Illustrated with 68 full-page half-tone and colored plates,
including nearly loo figures. Royal octavo, 256 pages. Bound in
extra cloth. Price, $2.50 net. F. A. Davis Company, Publishers,
1914-16 Cherry street, Philadelphia, Pennsylvania.

CULBRETH'S MATERIA MEDICA.*

This book discusses drugs and remedies arranged, not in their
alphabetical order, or in groups determined by similarity of action, but
in the order in which the sources from which they are derived occur,
when such sources are classified according to plant or other family
relationships. The subject is treated under five heads. I. Organic
Drugs from the Vegetable Kingdom. II. Organic Drugs from the
Animal Kingdom. III. Inorganic Drugs from the Mineral Kingdom.
IV. Organic Carbon Compounds. V. Non-Pharmacopeial Organic
Carbon Compounds. The plants and other members of the vegetable
kingdom that are discussed, and the particular part from which the
drug is collected, such as root, leaves, seeds, et cetera, are illustrated, a
feature that adds greatly to the value of the work. The subject as a
whole is considered primarily from the point of view of the botanist
and chemist, and secondarily from, that of the therapeutist. The work
illuminates what has hitherto been a shaded side of the subject of
materia medica, but would seem to be adapted rather to the needs of
the postgraduate and practitioner in medicine than to the needs of the
undergraduate medical student. d. l. p.

*A Manual of Materia Medica and Pharmacology for Students
and Practitioners of Medicine and Pharmacy. Comprising all Organic
and Inorganic Drugs which are and have been official in the United
States Pharmacopeia, together with important Allied Species and Useful
Synthetics. By David M. R. Culbreth, Ph. G., M. B., Professor of
Botany, Materia Medica and Pharmacology in the University of Mary-
land, Departments of Medicine, Pharmacy and Dentistry. Fourth
edition. Revised to accord with the new United States Pharmacopeia,
Eighth decennial revision. Octavo, 976 pages, 487 illustrations. Cloth,
$4.75, net. Lea Brothers & Company, Publishers, Philadelphia and
New York, 1906.

WILLIAM JAMES HERDMAN, Ph. B., M. D., LL. D.

(SKR PAGE 564)

% itesician ul^ Sturgeon

A PROFESSIONAL MEDICAL JOURNAL.

VOLUME XXVIIL DECEMBER, 1906. NUMBER XII.

ORIGINAL ARTICLES.

MEMOIRS.

SOME CARDIAC ARHYTHMIAS.*

LAWRENCE C. GROSH.

The most frequent form of cardiac arhydimia is that which occurs
during respiration- — ^pulsus irregularis respiratorius. It has long been
known that the pulse is accelerated during inspiration and retarded dur-
ing expiration. This physiologic respiratory irregularity is seen nor-
mally only when the respiration is exaggerated. When it occurs during
ordinary breathing, or when it occurs during superficial breathing
(which it rarely does), and especially when it persists during temporary
suspension of the breathing it denotes an increased irritability of the
nervous mechanism of the heart, upon which this irregularity depends.
More than twenty years ago it was demonstrated that change in the
volume of the lungs of dogs causes reflexly variations in the inhibitory
fibers of the vagus. It was also shown that the inhibitory fibers to the
heart vary in degrees of tonicity, even when the volume of the lung
remains constant.

The clinical significance of this irregularity is not difficult to under-
stand, when its periodicity and its relation to respiration are kept in
mind. The gradual inspiratory shortening of the pulse periods, ending,
as they do with the termination of inspiration, and the almost imme-
diate lengthening of the pulse period as expiration begins will not be
easily misinterpreted. In some exceptional cases this form of irregu-
larity persists when breathing is suspended. When this occurs the dif-
ference in the length of the pulse period is not so marked as when
respiration is in progress, although a certain amount of periodic change
is noticed.

Respiratory irregularity occurs most frequently in young people.

•Read before the Clinical Society of the University of Michigan, November
7. 1906.

630 ORIGINAL ARTICLES.

It is equally true that young persons are most susceptible to atropin
which quickens the pulse by removing the inhibition of the vagus.
Lommel found that when this respiratory irregularity occurred in con-
valescents it was most marked in persons under the age of puberty.
Mackenzie, Lommel and Rehfisch have found this form of irregularity
most marked in the convalescents from fevers. It occurs in neuras-
thenics, in meningitis, and in diseases of the brain substance. It may
also occur in mitral diseases when bradycardia has been produced by
administering one of the digitalis group. When this irregularity occurs
in the bradycardia of convalescents it cannot be implied that it is a sign
of weakening of the heart, nor that the heart muscle was weakened
before the arhythmia occurred. Fuchs, Rehfisch and Braun have shown
that pulsus irregularis respiratorius disappears when atropin is given.
When it occurs in a marked degree it shows that there is an increase
in the irritability of the extra cardial nervous system, and the cardiac
arhythmia is simply an indicator of some reflex nervous influence out-
side of the heart.

The diagnosis of this even within its physiologic limit, especially its
respiratory acceleration, shows a very irritable state of the vagus cen-
ter. The absence of inspiratory acceleration particularly on very deep
inspiration makes it doubtful whether the heart is under the influence
of the inhibitory fibres of the vagus at all. The irregularity that occurs
next in frequency is the arhythmia and extrasystole. An extrasystole
is the result of an abnormally early stimulus. In man the places from
whence the stimuli can arise are the auricle, the auriculoventricular
junction and the ventricle.

The diagnosis of the place of origin of the abnormally early-occur-
ring stimuli is made possible by making graphic registrations of the
arterial pulse or the apex beat simultaneously with the venous pulse.
The importance of registering the nervous pulse in the analysis of car-
diac irregularities was first pointed out by James Mackenzie in 1893,
and later reaffirmed by Hering and D. Gerhardt. This is of an especial
importance in the proper interpretation of arhythmia due to extrasys-
tole (or premature contraction). The extrasystole that arises from
the ventricle can be identified by its full compensatory pause, that is,
thfe length of the irregular beat is equal to two or more than two pre-
viously normal beats, and the percussion stroke of the following beat
appears very high. It can occur as an interpolated extrasystole when
it occurs at the end of diastole and at about the time when the regu-
lar rhythmic stimulus would have occurred, and when this occurs the
length of the irregularity is about that of a normal beat.

Cushny has demonstrated that this interpolated extrasystole never
occurs when the extrastimulus arises in the auricle, nor does it occur
when the ventricle is beating with its own rhythm and an extra
stimulus is developed in the ventricle itself. Retrograde extrasystoles
can occur in the auricle when the stimulus arises in the ventricle and
spreads back to the auricle and in this way disturbs the auricular

SOME CARDIAC ARHYTHMIAS. 531

rhythm. This generally occurs toward the end of a series of ventricu-
lar extrasystoles and shows itself in tracings of the jugular pulse as an
arhythmic auricular beat occurring too early, but later than the ven-
tricular extrasystole which caused it. When experimentally extra-
systole arises at the auriculoventricular junction the auricle can beat
at the same time as the ventricle or just before or just after it.

In man the only one of these that has been demonstrated is the
auricular extrasystole that occurs just before the ventricular extra-
systole in which the interval between the auricular extrasystole and
the ventricular extrasystole is shorter than the interval of this previous
auricular and ventricular extrasystole so distinguishing this auriculo-
ventricular extrasystole from an auricular extrasystole. So far expe-
rience in the study of extrasystole has shown that while extra stimuli
occur in the heart, they arise much more frequently from the ventricle
and auriculoventricular junction than from the auricle, that is, the
extra stimuli generally arise from places other than the normal seat of
origin of stimuli. — the junction of the right auricle and the great veins
that empty into it (the remains of the sinus venosus) . Notwithstanding
this we know that subsidiary stimulus-generating centers can by use
develop into chief centers, that is, we are certain that the ventricle and
the auriculoventricular junction can at times dominate over the auricu-
lar center of stimulus generation, and it is possible that while extra-
systoles are being generated from one of these abnormal centers that
they can in and of themselves produce irritants in the heart muscle in
the form of a heterotopic stimulus.

When the question is raised as to just what is the nature of this
extra stimulus we are certain that it can be of a mechanical nature.
We must also consider that it can be of a biochemical nature, for it is
possible for certain substances to increase the excitability of the heart
muscle and in this way bring about extrasystoles, that is, they can
result from the degree of stimulation and from the susceptibility of the
heart muscle to react to stimuli. Which of these two factors is at work
at a certain time is difficult to say with certainty. From the experi-
mental work that has been done with isolated mammalian hearts that
have been transfused with Ringer's solution and injected with substances
of the digitalis group, calcium, et cetera, extrasystoles have been pro-
duced that are like those produced by warming the heart or stimulating
the accelerator nerves, thereby increasing its stimulability. But it is
much more difficult and uncertain to produce extrasystoles in this
manner than by electrical or mechanical means. •

The important question arises whether extrasystoles can result
directly from nervous influences. This can be answered in the nega-
tive, for nervous influences can produce extrasystoles indirectly only,
and that when as the result of reflex vasoconstriction the resistance
to the outflow from the left ventricle is increased. In this sense only
can stimulation of the cardiac nerves produce extrasystoles, for direct
stimulation of any of the extracardial nerves cannot produce them by

632 ORIGINAL ARTICLES.

any known form of stimulation. In all probability extrasystolc
arhythmia is myogenic in its origin, that is, it is the result of catabolic
or mechanical changes in the heart muscle ; at least it is the result of
catabolic and not extracardial changes, and when we consider the time
element of the occurrence of extrasystoles we can form an opinion as
to which part or cavity of the heart is giving rise to the extra stimulus.
When extrasystoles occur in a pulse tracing they give the picture of a
bigeminous pulse. They occur sporadically or rhythmically after a
certain number of normal beats, or they can occur continually, and
there is no fundamental difference between a sporadic or continual
bigemini for they are both due to the occurrence of extrasystoles and
both result from the €ame cause. It is not uncommon for two or three
extrasystoles to occur in succession, and thus develop true tri- or
quadri-gemini, as Pan has described. Or, a whole series of extrasys-
toles may continually follow one another and so produce an extra-
systole tachycardia.

That an extrasystole tachycardia exists is certain from the experi-
mental work of Hering in 1900. Pan also has shown that with the
help of tracings taken of the venous pulse he could demonstrate the
same thing in man. D. Gerhardt, A. Hoffman, Mackenzie and Wencke-
bach have found the same to be true in paroxysmal tachycardia. In
these cases the rhythm would double itself. When in these cases good
jugular tracings are obtained they demonstrate that the stimulus arises
either in the auriculoventricular junction or in the ventricle. When
extrasystole arhythmia occurs it is a clinical manifestation of trouble
within the heart itself, and the abnormal stimulus which causes the
irregularity arises within the myocardium. The functional disturbance
resulting from the occurrence of extrasystole can be very slight. For
they can be caused by a very slight stimuli.

Sporadically occurring extrasystoles have very little clinical sig-
nificance, but it must be remembered that some abnormal stimulus
within the heart is causing them, smd when extrasystoles occur in
clusters they are much more important even though the patient does
not seem to be much disturbed by them, for they show that a marked
stimulus is at work causing them, or that the heart muscle is ver>'
irritable. An irregularity that stimulates extrasystole arhythmia is the
perpetual irregular pulse (which occurs when the ventricle takes on
the fhythm the dominating stimulus production arises within it). By
this is to be understood a continual irregular pulse, whether the heart
beat is rapid or slow. It is not influenced by respiration and longer
and shorter pulse periods follow one another in a most irregular
manner. This form of irregularity is always accompanied with a
venous pulse of the ventricular type. The combination of this irregu-
larity with venous pulse of ventricular type makes the analysis of it
difficult ; for in a venous pulse of ventricular type the auricular wave
is almost always obliterated. The place of origin of the abnormal
stimulus that could cause this form of irregularity could be the auricle,

SOME CARDIAC ARHYTHMIAS. 633

or the auriculoventricular fibers, but could hardly arise in the ventricu-
lar wall itself, for the rate is too rapid. The rate of beat when the
ventricle is beating automatically is about thirty per minute. It
cannot depend upon the vagus, for when atropin is given the rate of
beat will almost double itself, but the arhythmia persists. When digi-
talis is administered the pulse appears to the touch to become more
regular, but when tracings are taken of it the same arhythmia is seen
to be present. From everything that can be gleaned so far the origin
of this irregularity is the heart muscle, and the only examples in
which it has been found have been cases of valvular defects where the
venous side is affected, in other words, when there is tricuspid regurgi-
tation, either organic or relative. It cannot be claimed that it occurs
only in tricuspid regurgitation, but at present it has been reported only
in conjunction with this lesion, and in combination with ventricular
venous pulse. It does not occur with mitral disease unless it is asso-
ciated with regurgitation of blood through the tricuspid valves. Hering '
concludes that its seat of origin must be at the primary seat of stimulus
production within the right auricle, and not the left. For when in a
patient with this arhythmia the venous pulse changes from the ventricu-
lar to the auricular type, then it disappears with the change and returns
if the venous pulse changes back to the ventricular type.

PARTIAL OR COMPLETE HEART BLOCK.

By this form of irregularity is to be understood an imperfect
conduction of the impulse from the auricle to the ventricle. In man
two forms of this have been found, first, a failure of some of the beats
to pass from the auricle to the ventricle — a partial heart block ; and
second, when none of the impulses are conducted from the auricle to
the ventricle, resulting in complete heart block.

Partial heart block has been seen in animal experiments for a long
time, but in man it was first described by Mackenzie in 1902. Since
this time it has frequently been seen by SchmoU, Osier, Gerhardt,
and others have made many clinical reports in such cases. Most of
these cases occurred during and by the use of digitalis, for digitalis not
only slows the pulse through its central action on the vagus, but it also
interferes with the conductivity of the auriculoventricular fiber. Previ-
ously most of the cases of heart block or falling out of ventricular beats
were ascribed to this effect of digatalis on the vagus center; but this is
not sufficient, for it was noticed that in these cases there was an auricu-
lar tachysystole instead of an auriculobradysystole which was noticed
. by Rihl. When atropin was given hypodermically the falling out
of ventricular beats ceased, but the rate of the auricular beats remained
the same so that in time every auricular beat was followed by a ventricu-
lar contraction, this effect being a peripheral vagus effect, not a central.
It has been long known that stimulation of the vagus can cause the
ventricle beat to fall out without interfering with the auricular rhythm^
and now it is known that this is due to the effect on the conductivity

534 ORIGINAL ARTICLES.

of the auriculoventricular fibers. This is well shown from the fact
that in some of these reported cases of falling out of the ventricular
beat caused by digitalis the rhythm of the auricular beat has not been
interfered with. It is now well known that digitalis has a deleterious
effect on the auriculoventricular fibers. Partial heart block has been
reported by Mackenzie occurring in the convalescents of influenza, and
Gerhardt has noted the same results in the convalescents from rheu-
matism.

Complete heart block is of greater significance. That is, when
the conductivity of the auriculoventricular fibers is destroyed, if no
impulses are conducted from the auricle to the ventricle and they are
beating with their own automatic rhythm independently of each other.
Critical analysis of the reported cases of Stokes- Adams' syndrome shows
that bradycardia and arhythmia are due to this cause. Erlanger has
brought out the interesting fact in his experiments on dogs that when
he applied a clamp to the auriculoventricular fibers a 2-1, 3-1 or 4-1,
et cetera, rhythm could be produced, and when it was produced grad-
ually in this way the ventricle took on its own rhythm very soon, but
when he applied the pressure with the clamp' rapidly the ventricle
stopped for a long time before it began to develop automatic beats of
its own. Now, when the fainting fits and epileptiform seizures occur
in Stokes-Adams' syndrome they are caused by sudden blocking of the
conductivity of the auriculoventricular fibers, for when later in the
disease (if the patient live long enough) this blocking of impulses from
the auricle to the ventricle occurs more gradually, and then the ven-
tricle takes on its own rhythm more quickly. The long asystole of the
ventricle does not occur, and these seizures cease. It is easy to tell
when the ventricle is beating from its own rhythm for then we have
a pulse of about 30 per minute. Temporary partial heart block can
be caused by vagus stimulation as well as lesions of the auriculoven-
tricular fibers, but this is always temporary, for the ventricle will soon
begin to beat again, even under the strongest experimental stimulation,
but this is not so in complete heart block, for vagus stimulation has
no effect on this, for then the ventricle is responding to its own stimu-
lus. Hence complete heart block shows that conductivity of the
auriculoventricular fibers has been completely destroyed, whereas,
partial heart block may be due to partial destruction of this conduc-
tivity, or to reflex stimulation of the vagus.

Looking at it from a practical standpoint, if we find the pulse in
the neighborhood of 30, and this does not markedly quicken within an
hour after about a sixtieth of a grain of atropin hypodermically, then
we can be reasonably certain that there is a lesion of the bundle of His,
and that heart block exists. This test has been proven to be true
in four cases of Belski, one of Erlanger, one by A. Schmidt, one by
Finkelberg, and in a case of mine. As far as I know there is only
one case of certain lesion of the auriculoventricular fibers in which
this test failed. It is the one reported by E. Schmoll in San Fran-

SOME CARDIAC ARHYTHMIAS. 535

•

Cisco. He reported this year a case of Stokes-Adams' syndrcwne with
three to five auricular contractions to one ventricular with a pulse
of about 30, and at the time of the attack the auricle continued in an
undisturbed rhythm whereas the ventricle stood still. Upon known
experimental grounds he made a diagnosis of lesion of the auriculo-
ventricular fibers, and microscopic examination clearly showed a
sclerosis of the bundle of His under the membranous septum.

Luce, in' 1902, published a case of Stokes-Adams' syndrome with a
pulse of 30, the autopsy of which revealed a sarccxna of the upper one-
third of the ventricular septum, just in the path of the auriculoventricu-
lar fibers. One case of Erlanger recovered under the use of iodides
where gumma had been diagnosed.

Complete heart block can be present for years, as one case of
Rihl's, and one of my own, has done. Such patients are not able to
do much physical work and the condition must be considered a grave
one.

PULSUS ALTERNANS.

The condition was first described by Traube in 1872. In this the
size of the pulse alternates, a large beat followed by a small one and
this by a large one. In 1902 Hering found that pulsus alteroans can
be caused by heart bigeminus. When we consider the time of occur-
rence of the small beat in relation to the large one we find that when
this small beat occurs early that it is due to a heart bigeminus. When
the small one occurs at the proper time it can be caused either by
bigeminus or altemans of the heart, and when it occurs late it is gen-
erally due to heart altemans.

Experimental observations on mammalian hearts have shown that
alternating beats can arise from the auricle, or the ventricle, or both
simultaneously. In this case the small auricular contraction can cause
a large ventricular beat, or vice versa. This form of irregularity is
caused by changes in the contractility of the diflFerent chambers of
the heart, and is not due to improper conduction of impulses, and only
by the direct effect of the special cause on these different cavities.
Almost all of the cases of this affection have occurred in nephritis with
high blood pressure. Some of these showed signs of myocardial
insufficiency and some few cases were of partial block. It is the sign
of serious myocardial insufficiency.

Mackenzie associates pulsus altemans with angina pectoris, but
certainly pulsus alternans may also occur without angina. Rihl claims
that when the rate of the heart increases in a case of pulsus altemans
it becomes more marked and he notes that it only occurs markedly
when the pulse is over ninety. When it occurs with a slower pulse it
is more distinct when the pulse rate increases and becomes less distinct
when the pulse slows again. Volhard observed the same changes. It
is possible that pulsus altemans is due to disturbed nutrition of the
myocardium, and when this disturbance is slight it occurs only when
the heart beats rapidly. If this is so then it can be inferred that when

536 ORIGINAL ARTICLES.

•

the pulsus alternans occurs with an average rate of heart beat the more
severe are the nutritional changes. The size of the small beat gives us
an idea of the severity of the condition, for the smaller it is i^ ccmi-
parison with the large one, the more severe are these changes. At
any rate it is a sign of grave disturbance of contractility.

I have endeavored to present to you as briefly as I could the clinical
manifestation of some cardiac arhythmias.

When, in conclusion, we sum them up as to the frequency of their
occurrence, the first two occur much more frequently than the last
three, and complete block and alternans are less frequent than the so-
called perpetual irregular pulse.

Combinations of these different kinds of arhythmia must be kept
in mind, as extrasystoles can be met with in combination with any of
the others.

We can tell whether the auricles or ventricles are affected but
cannot tell whether it be the right ones or the left ones, as clinical
hemisytole does not exist.

The heart plays the part of indicator of extra cardial functional
disturbances in pulsus irregularis respiratorius, and in certain of the
disturbances of conductivity due to the vagus. In all the other forms
of cardiac arhythmia the heart itself is at fault, and the irregularity is
due to the pathologic change within it, and this works directly on the
heart or reflexly ; as vasomotor disturbances can produce extrasystole.

To sum up:

( 1 ) They are all disturbance of function.

(2) From the analysis of the irregularity we are able to tell
whether the trouble is within or without the heart.

(3) The tracings of many cases of irregularity indicate whether
the auricles, ventricles, or auriculoventricular fibers are affected.

(4) Other cases of arhythmia g^ve us light as to the severity of
the cardiac disease, for when perpetual irregular pulse, complete block,
or alternans occur (especially when it occurs with the average rate of
pulse beat), they are signs of severe conditions.

A lesion of a particular part of the heart is shown directly by
complete heart block, whereas perpetual irregular pulse is an indirect
sign because of its combination with the ventricular venous pulse,
which is a sign of severe valvular defect.

Toledo, OhiOf 339 Michigan Street.

OPSONINS.*

ERNEST B. KRADLEY. A. B., M. D.

When Doctor Edmunds asked me, about two weeks ago, to come
to Ann Arbor and give a talk on ''Opsonins," I consented only upon
the condition that I might talk informally without going into the
subject scientifically. My discourse contains nothing original, and I

♦Read before the Ann Arbor Medical Club.

OPSONINS. 537

shall not refer to our work except casually, as the results of that work
are published elsewhere.^

In conjunction with Doctor Nathaniel B. Potter and Doctor
Norman Ditman, of New York, I have worked for about nine months
on this subject. I hope to be able to give a general summary of the
work which has been done, especially that of Doctors Wright and
Douglas, of Saint Mary's Hospital, London. Doctor Wright has
within the past few weeks been in this country, and his lectures before
the Academy of Medicine of New York have aroused the greatest
enthusiasm in the subject. It was my pleasure to be present at a
demonstration of his technic given by Doctor Wright at the Rockefeller
Institute. The word "wizard^' seems to me to be appropriately applied
to Doctor Wright, after seeing birii work. In New Yoric the Board of
Health and the Rockefeller Institute are going into the work, and
Doctor Ross, of London, is now giving a course in technic to a class
at that institution Since 1903 Doctors Wright and Douglas have
contributed to medical literature many interesting papers on the sub-
ject of phagocytosis, and especially upon certain protective substances
in the blood — called by them opsonins. Metschnikoflf, the great expo-
nent of the phagocytic theory, and his followers believe that immunity
to bacteria depends wholly upon the action of certain cells of the body —
the phagocytes. By phagocytes is meant especially the polymorpho-
nuclear neutrophile leucocytes of the blood, and in what follows here-
after when we speak of phagocytes or leucocytes it is to this form I
refer. Metschnikoflf and his school believe that the only elements of
the blood responsible for phagocytosis are the white blood corpuscles.
They take no account of the fluid elements of the blood. Wright and
Douglas, however, approached the subject in quite a diflFerent way by
obtaining corpuscles free from sertmi. They call these "washed cor-
puscles," and since I shall have occasion in the course of what follows
to refer to them many times, let me briefly explain how they are
obtained.

For convenience the washed corpuscles were always procured from

human blood. The finger is pricked and about fifteen drops of bloo<i

allowed to drop into a one per cent solution of sodium citrate in 0.85

per cent salt solution. The citrate is to keep the blood from clotting.

The tube is put into a centrifugal device until all the corpuscles are

thrown down. The supernatant fluid is poured oflF and 0.85 per cent

sodium chlorid solution substituted. The corpuscles are again shaken

up and centrifugated and washed thus two or three times. Finally the

supernatant salt solution is pipetted oflF and the corpuscles are used for

washed corpuscles. The top layer of the corpuscles is particularly rich

in leucocytes, the "leucocytic cream," and so we use generally only this

portion.

* Potter, Ditman and Bradley: American JourmU of the Medical Sciences^ Attest,
1906, and Journal of the American Medical Association^ November 24, and December i,
1906.

538 ORIGINAL ARTICLES.

A few experiments will serve to show the work of Wright and
Douglas.

Mix together blood and staphylococci ; incubate fifteen minutes ; then
make a smear on a slide; stain and examine under the oil-immersicm
lens. We find that abundant phagocytosis has taken place. Every
leucocyte is crowded with cocci; we cannot count them, there are so
many in each leucocyte. Thus :

( I ) Blood + cocci = phagocytosis.

Now mix together washed corpuscles and staphylococci, incubate,
and examine as before. We find practically no phagocytosis at all.
Practically all the cocci lie outside the leucocytes. Thus:

(2) Washed corpuscles + cocci = 0 phagocytosis.

Now mix washed corpuscles and staphylococci and add blood
serum — any human serum will do. Incubate, and examine. We find
that phagocytosis has taken place just as when blood was used. Thus:

(3) Washed corpuscles + cocci and serum =r phagocytosis.

This shows that there is something in the serum which induces
phagocytosis. Does it act upon the leucocytes, stimulatii^ them, or
does it act upon the bacteria, altering them, so that they may be taken
up? Let us see. If we heat serum at 60° centigrade for ten minutes
all this substance is destroyed, and if we mix corpuscles, cocci, and
serum thus heated, incubate, and examine we find no phagocytosis.
Thus :

(4 Washed corpuscles + cocci + heated serum ^= 0 phagocytosis.

Now mix cocci and serum together, incubate for fifteen minutes,
and heat at 60° centigrade for ten minutes to destroy the protective
substance. If we add this mixture to washed corpuscles we find that
abundant phagocytosis takes place as in (3). Thus:

Cocci and serum fifteen minutes, then heat at 60° for ten minutes,
add washed corpuscles =: phagocytosis.

They (Wright and Douglas) thus showed that there is a substance
in the serum which acts upon bacteria in such a way as to prepare them
for phagocytosis. This substance they have called "opsonin," from a
Latin word opsono— I prepare food for.

THE NATURE OF OPSONIN.

The most important conclusions follow :

(i) The opsonin exists in the serum and acts upon bacteria and not
upon the leucocytes.

(2) Opsonin in normal serum is almost completely destroyed by
heating at 60° for ten minutes.

OPSONINS. 639

(3) Opsonins possess a high degree of specificity; for example, the
blood of a person may contain only one-half the amount of opsonin
necessary to counteract a tuberculous infection, and yet have a per-
fectly normal amount to resist a staphylococcus invasion.

(4) The leucocyte is an invariable factor in phagocytosis. It makes
no difference in the amount of phagocytosis whose leucocytes we use :
under the influence of a fixed serum the result is the same.

(5) The sera of different persons vary in the amount of opsonin
they contain.

(6) Opsonins are distinct bodies differing from the bacteriolysins,
agglutinins, antitoxins, et cetera.

The imix)rtance of the opsonin over previously discovered antibac-
terial substances arises from the fact that it can be measured fairly
accurately and easily. If we wish to measure the quantity of opsonin
to resist staphylococci in a patient suffering, say from furunculosis,
which is usually due to an invasion of staphylococci, we need four
things :

( 1 ) A few drops of the patient's blood in ord^r to obtain sufficient
serum.

(2) A few drops of blood of a normal person in order to have a
control serum.

(3) A suspension of staphylococci in salt solution.

(4) Washed leucocytes suspended in salt solution.

In a capillary pipette fitted! with a rubber teat equal volumes of
corpuscles, the bact/erial suspension, and the patient's serum are meas-
ured and mixed thoroughly by blowing out on a slide several times.
The mixture is then drawn up in the same pipette, the end is then
sealed in the flame, and the pipette placed in the incubator. In another
pipette, using the same technic, equal parts of washed corpuscles, bac-
terial suspension, and normal serum are likewise mixed and incubated.
At the end of fifteen minutes smears are made from each specimen,
fixed and stained. The number of staphylococci per leucocyte is
obtained in each case by counting the cocci in the first fifty polymorpho-
nuclear neutrophiles encountered and making an average. The ratio
of the average obtained with the test serum to that obtained with the
normal serum constitutes the "opsonic index." Thus, if the average
for the patient's serum is six cocci per leucocyte and that for the normal
serum is ten, the opsonic index to staphylococci for that patient would
be 6 -=- 10 or 0.6.

The washed corpuscles and the bacterial suspension are the same
in each case. They are constant factors. The variable factor is the
serum, and you thus compare the test with the normal. The amount
of phagocytosis depends upon the quantity of opsonin in the serum.
An index of 0.6 means, then, that this patient has six-tenths that
amount of opsonin necessary to combat successfully an invasion of
staphylococci. If the opsonins are specific it shows nothing of his

540 ORIGINAL ARTICLES.

resistance to inspection with other microorganisms. To learn this we
should have to employ the same method, using the suspension of the
germ in question.

From many thousands of determinations on all classes of infection,
several general conclusions may be drawn :

(i) In normal healthy individuals the opsonic index varies only
within slight limits (from 0.8 to 1.2), and varies only slightly from
day to day.

(2) In cases in which the bacterial infection is strictly localized
the opsonic index is almost always low, that is, below 0.8. Thus in
lupus the index to tubercle bacilli would be found to vary from 0.2 to
0.8 in different cases; or in furuncuk>sis the index to staphylococci
would be found to be about 0.6.

(3) In a generalized or systematic inspection the opscmic index
may be low or high, but varies markedly fr<Mn day to day; thus in acute
pulmonary tuberculosis the index to tubercle bacilli might be 0.3 one
day and two or three days later might be found to be as high as 1.8.

TREATMENT OF BACTERIAL INFECTIONS.

As outlined by Professor Wright, this treatment, briefly stated,
consists in inoculating the patient with dead microorganisms of the
species causing the infection. Thus in treating a case of furunculosis
we use a suspension of staphylococci killed by heating and suspended
in normal salt solution. These suspensions of dead microorganisms
Wright calls "vaccines." Thus we have a "colon vaccine" for colon
infections ; a "tubercle vaccine" for tubercular infections ; "gonococcal
vaccines";* "pneumococcal vaccines"; et cetera. These vaccines are
standardized by counting the number of bacteria by an ingenious
method devised by Wright.

Let us see what follows the inoculation of a staphylococcus vaccine
in treating a case, say of furunculosis. Shortly after the injection of
the vaccine there will be a period of diminished resistance on the part
of the body, as shown by a diminution of protective substances in the
blood. The particular protective substance that is measured is the
opsonin. At this time also the patient will probably be worse clinically.
This is called the "negative phase." Succeeding this after a longer or
shorter time, depending largely upon the dose of vaccine given, there
is an increase in the protective substance, the opsonin, above the origi-
nal the "positive phase." After a time this tends to wear off and if
another injection is given, we get the same train of events, first a fall
in the opsonin — the "negative phase," followed by a rise — the "positive
phase." This is illustrated by the following diagram.

Let us say that the patient has an index of 0.7, and on the second
day of the month (see diagram) we inoculate him with a vaccine con-
taining about two hundred million staphylococci. At first we get a

OPSONINS.

541

fall in the opsonin to X, the "negative phase." This is followed by a
rise to B. After a day or so we give another inoculation, and we get
another negative and positive phase. By proper dosage we may be
able to raise the index to 1.2 or 1.4 — in rare cases even as high as 2.0.
As the opsonin falls the patient gets worse, but as it rises he gets better.

/ 7 -^

i.S
i.3

/./
/.O
OS

0.5

/■

t a. 3 4 S € 7 9 9 /o/t ix n/i. ijrmy /« '1 a»i»
JD A yS OF Ho'^T H

and if we can keep it above i.o for a time he will probably get well.
The reason that it is necessary to measure the opsonin is this : Should
we inoculate a patient during the negative phase, there will be a further
fall in the opsonin, or if we g^ve too large a dose the negative phase
will be unduly prolonged. This is probably one reason why tuberculin
had such a bad effect in the hands of those who first used' it. Too much
was given at improper intervals, so that there was a cumulation in the
direction of the negative phase. When we give too small a dose, we
may get no negative and consequently no positive phase, so we have to
give the right dose and at the right time. The initial dose can only
be determined by trial, but we start with the dose sufficient to give the
least negative phase, and reinoculate only when the ix)stive phase begins
to diminish.

I will quote a case reported by Wright and Douglas :
The patient was a man who had suffered from boils almost contin-
uously for four years. His opsonic index was 0.6 to staphylococci
on the first examination, and i.i on the second. He was inoculated
with 2,000,000,000 dead staphylococci. On the day after, the opsonins
fell to 0.78, negative phase. From this point there was a steady rise
in opsonic power until the original level i.i was reached a week later.
A few days later the index was 1.4, the positive phase. While the

542 ORIGINAL ARTICLES.

opsonic power was still high another inoculation was given which
resulted in, first a n^;ative phase, then a rapid rise for a day or two
until the index was 2.0 or twice normal. The clinical result was
eminently satisfactory. After several wedcs of treatment the boils
completely disappeared.

It can be seen, then, that it is of the utmost importance in inoculation
to measure the opsonin, for it is only in this way that we can tell the
effect of a vaccine and when it is safe to reinoculate. It is believed that
the reason why localized infections do not get well of themselves is
because insufficient amounts of the bacterial substances are absorbed to
cause a rise in opsonic power.

TREATMENT OF TUBERCULOSIS.

For our purpose we divide tuberculous cases into two classes :

(i) Those in which the infection is strictly localized, such as lupus,
tubercular glands, tuberculosis of subcutaneous tissues, et cetera.

(2) Those which are systemic, as, for example, are most cases of
pulmonary tuberculosis — excepting, of course, certain cases of early or
quiescent phthisis. The average index to tubercle bacilli in a large
series of supposedly healthy persons varies between 0.8 and 1.2. In
the class of strictly localized infections the index is almost uniformly
low. In cases of lupus the index may be as low as o.i. This low index
is supposed by Wright to antedate the infection and to be the cause
and not the result of such infection. In these cases the vaccine used
is Koch's new tuberculin, which is in all respects similar to the other
bacterial vaccines, consisting as it does of the finely pulverized bodies
of tubercle bacilli.

Many cases of lupus, tubercular cystitis, tubercular glands, et cetera,
have been reported as cured or benefitted by the inoculation of tuber-
culin controlled by the estimation of the opsonic index. The train of
events following an inoculation is in all respects similar to that described
above. There is the negative followed by the positive phase, just as
above. Great care must be taken in the treatment with tuberculin not
to reinoculate during the negative phase, and the inoculations have to
be given at longer intervals than in the case of staphylococcus vaccine,
for the increase in opsonic power is maintained over a much longer
period. Wright advises as an initial dose i-iooo milligram of tuber-
culin powder and subsequent reinoculation with a slightly larger dose
only when the positive phase begins to diminish.

The treatment of active pulmonary tuberculosis is very dangerous,
for such a person is constantly absorbing tuberculin from the site of
infection. It is for this reason that we find the index fluctuating in
these cases. One day it may be 0.4, several days later 1.3, and again
the next day as low as 0.6. Since we cannot regulate the amount of
tuberculin thus absorbed we cannot estimate our dosage. Wright has
suggested that such patients be put to bed until the tuberculo-opsonlc
index gets to one point and stays there — then one may beg^n treatment
with tuberculin.

OPSONINS. 643

DIAGNOSIS.

That the estimation of the opsonic index might be a help in diag-
nosis is evident, and certain claims have been made for it. I shall not
have time to go into this in detail, but one point I wish to relfer to.
The opsonin in various fluids of the body varies to a certain extent. In
tuberculous peritonitis we find- that the blood serum contains more
opsonin than the ascitic fluid, and the same is true in regard to the
chest-serum in cases of tuberculous pleurisy. It has less opsonin than
the blood serum of that patient. The conclusion is, that the bacteria
growing in a certain focus use up the opsonin in this fluid. Hence the
fact that operation so often cures tubercular peritonitis, owing to the
fact that the old serum or ascitic fluid low in opsonic power is drawn
off and a new fluid richer in opsonin is poured out. By these means
some rather remarkable diagnoses have been made. I am sorry that
I cannot go more deeply into this part of the subject, but that finally
we shall have an aid to diagnosis in the estimation of the opsonic index
I do not doubt.

I shall close by quoting from Doctor George W. Ross, of London,
a list of bacterial infections that have been successfully treated by
opsonic methods. The cases have been reported for the most part by
men who are in all respects reliable, and some results claimed are almost
marvellous.

BACTERIOLOGICAL CLASSIFICATION.

A. — Due to Staphylococcus Pyogenes :
(i) Furunculosis.

(2) Pustular acne.

(3) Sycosis.

B. — Due to Pneumococcus :
(i) Empyema.

(2) Cystitis.

(3) Suppuration of the antrum.

C. — Due to Colon Bacillus :
(i) Cystitis.

(2) Various local infections.

(3) Sinusitis after gall-bladder operations.

D. — Due to Gonococcus :
(i) Gleet.

(2) Gonorrheal rheumatism.

(3) Acute gonorrhea.

E. — Due to Tubercle Bacillus :
/. — Strictly Localized Tuberculosis:

(i) Lupus and tuberculous ulceration of the skin and subcutan-
eous tissues.

(2) Tuberculous disease of bones and joints.

(3) Tuberculous cystitis.

544 ORIGINAL ARTICLES.

(4) Tuberculous nephritis.

(5) Tuberculous epididymitis.

(6) Tuberculous peritonitis.

(7) Tuberculous adenitis.

(8) Tuberculous laryngitis.

(9) Tuberculous iritis.

//. — Not Strictly Localized Tuberculosis:
Pulmonary tuberculosis.

In conclusion, I wish to say that I have done but scant justice to
the subject, and have been able to treat it in only the most superficial
manner. For your forbearance I thank you very much.

Ntuf York City,

PRIMARY BASAL-CELLED CARCINOMA OF THE APPEN-
DIX; REPORT OF A NEW CASE WITH SOME OBSER-
VATIONS BEARING UPON ITS HISTOGENESIS.

ALDRED SCOTT WARTHIN, Ph. D.. M. D.

PKOFBtSOK OF PATHOLOGY AMD DIKBCTOR OP TMB PATHOLOGICAL LABORATORY IN TUB UMIVBRSITY

OP MICHIGAN.

Primary carcinoma of the appendix is of interest, both to the
clinician and pathologist, for a number of reasons. In the first place
it is probably of more common occurrence than is at the present time
supposed, is usually discovered only on microscopic examination, pre-
sents an individual pathologic picture, and is of very slight malignancy,
no definite recurrence after operation having as yet been established.
It has also been recently suggested that primary carcinoma of the
appendix plays an important part in the origin of cecal carcinomas.

In the review of this condition by RoUeston and Jones {American
Journal of the Medical Sciences, June, 1906), forty-two genuine cases
of primary malignant disease of the vermiform appendix were col-
lected. Of these cases 80.9 per cent have been reported since 1900,
and this fact must be taken as evidence that it is not so rare as has
been thought. With the increasing routine examination of appendices
removed at operation, this number is increasing rapidly, ten or more
cases having been mentioned in the literature since last June, and the
writer is personally aware of a number of observations that have as
yet not been reported. Such a case was discovered in this laboratory,
three years ago, in the routine examination of appendices removed in
the University gynecological clinic (Doctor Peterson). As this case
presents the characteristic and peculiar variety of carcinoma found in
practically all of the cases of malignant disease of the appendix, it
seems important at this time to add it to the casuistics of this condition,
particularly as an unusually thorough microscopic examination was
made. The entire appendix was cut in serial sections, and these were
studied with particular reference to the reljttionship of the cell nests
to each other and to the various tissues of the appendix.

PRIMARY CARCINOMA OF THE APPENDIX.

545

Further, in connection with this case it is desirable at the present
time to call attention to the not infrequent occurrence of epithelial
nests and glands in the deeper layers of the appendix wall having
no connection with the epithelium of the mucosa. That such snaring-
off of mucosal epithelium is not uncommon in the spontaneous healing
of ulcerative appendicitis and in chronic obliterative appendicitis is

FIGURE I— LOW POWER VIEW OF APPENDIX, SHOWING LUMEN OBLITERATED BY BASAL-
CELLED CARCINOMA.

clearly shown by our routine examinations, and the question arises as
to the, part played by this in the origin and development of primary
appendiceal carcinoma. It seems probable that there may be a close
etiologic relationship between the two conditions. Another observa-
tion of epithelial structures in the muscularis and subserosa of an
appendix showing no chronic inflammatory changes suggested also a
possible origin in a congenital anomaly.

546 ORIGINAL ARTICLES.

The clinical history of the case previous to the operation is without
any definite bearing upon the pathologic condition : — Mrs. M. G., aged
thirty-two, married eight years and has had one child, now twenty-
two months old. Her trouble began about nine months ago with
swelling of the elbow diagnosed as ^'periostitis." A few months after
this she began to have pain in right inguinal region and then noticed
pus in her urine. Micturition was painful, but the flow of pus was not
constant and gradually diminished. A clinical diagnosis of pus-tube
was made and she was operated upon by Doctor Peterson on August
5, 1903. A mass of adhesions was found about the right tube and
ovary, involving the appendix, cecum and small intestine. The appen-
dix was freed from the adhesions and removed. An abscess containing
about an ounce of pus was present in the right ovary, and this organ
in connection with the right tube was removed. The patient recovered
from the operation, and a few months ago was reported as perfectly
well.

PATHOLOGIC EXAMINATION.

The right ovary contained a chronic abscess. The right tube
showed a condition of chronic purulent salpingitis with atrophy of the
plications and mucosa. The serous surfaces of both tube and ovary
presented a chronic peritonitis with numerous remains of adhesions.
No evidences of tumor-growth were found in either ovary or tube.

Appendix. — To the naked eye the appendix appeared somewhat
irregularly thickened and covered with the remains of peritoneal
adhesions. It was about six centimeters long, straight and of firm
consistency. Cut transversely, the lumen appeared to be obliterated
throughout its length. Several small whitish nodules were seen
beneath the serosa, but there was nothing in the gross appearances to
suggest the existence of malignant disease or the presence of any
condition other than that of a chronic appendicitis. Sections were
made, as is our routine custom, from the proximal, middle and distal
portions. All of these presented a similar picture, varying somewhat
in degree and relationship.

The lumen was completely obliterated by a framework of dense
fibrous connective tissue containing oval, round or oblong spaces filled
with rather small spheroidal cells having deeply-staining nuclei and
narrow rim of protoplasm about the nuclei. The cell-nests varied
greatly in size. In many of them the cells were contracted away from
the connective tissue, so that a clear space was left entirely around the
cell-mass, but in others there was no shrinkage and the outer rim of
cells next to the connective tissue stained more deeply, sug^gesting the
appearance of the lowest layer of the rete Malpighii. No reticulum or
blood-vessels were found in the cell-nests.

No remains of the mucosa of the appendix could be found. No
glands, columnar epithelium or lymphoid tissue were found in any
part of the obliterated lumen or wall. No mucoid or colloid degen-
eration was seen. Slight vaculation was present in some of the larger

PRIMARY CARCINOMA OF THE APPENDIX. 547

cell-nests. The subniucosa showed an extensive hyperplasia of dense
connective tissue into the lymph-spaces of which similar cell-nests and
cords were infiltrating. These nests, as a rule, were longer and
narrower than those in the lumen, their axis coinciding with that of the
circular muscular fibers. The muscle-coats were very thick, and
showed also much hyperplasia of connective tissue. Small nests of
cells of the type described above were found occasionally in the lym-
phatics. The serosa, likewise, showed a marked connective-tissue thick-
ening, and in the subserosa the nests of cells were more numerous and
larger than those in the muscle coats. The small whitish nodules in
the subserosa consisted of small tumor-masses having thinner trabec-
ulse and larger cell-nests than in the lumen. They were situated around
large blood-vessels, and from their location and appearance were inter-
preted as lymphogenous metastases in the subserosa. No direct con-
nection could be shown between these and the main growth in the
lumen, although the lymphatics running towards these areas contained
interrupted cords of tumor-cells. All appearances suggested a carci-
noma primary in the lumen, gradually infiltrating the submucosa and
extending through the lymphatics into the subserosa and there forming
secondary nodules.

Toward the proximal end the appendix as a whole became some-
what constricted, the lumen much smaller but obliterated in the same
way with fibrous connective-tissue trabeculae containing cell-nests as in
the middle and distal portions. At the extreme proximal end the
tumor nests were fewer and smaller, but persisted to the last section.
It is, therefore, probable that the growth extended as far as the cecum
but as the patient has for three years shown no signs of intestinal
involvement such an extension into the cecal wall may not have taken
place. On the other hand, there is still a possibility of a future invasion
of the cecum from the stump of the appendix.

Throughout the length of the appendix there was a striking absence
of any active inflammatory reaction in the form of a small-celled infil-
tration, although small groups of these, mostly mononuclears and
plasma-cells, occurred occasionally in the outer cfttts of the wall.
Few eosinophils were found. The connective tissue throughout was
greatly increased, and many of the blood"- vessels showed greatly thick-
ened walls. In general the coats of the appendix showed changes
suggesting an old chronic inflammation. It is, of course, impossible to
say whether this inflammation antedated the development of the tumor,
or was secondary to it. The absence of cellular infiltration might be
taken in favor of the former view or the process interpreted as a slowly
progressive connective-tissue hyperplasia due to the irritation of a
slowly developing and relatively benign neoplasm.

In its general characteristics this neoplasm resembles very closely
the basal-celled carcinoma of the skin commonly occurring in the clin-
ical form of a rodent ulcer. Their resemblance is so close in the little
circumscribed nodules in the subserosa that I do not believe a differ-

648 ORIGINAL ARTICLES.

ential diagnosis to be possible. The relatively benign character of the
growth bears out the resemblance. Because of the large size of many
of the cell-nests as compared to the thickness of the trabeculae, the
growth was diagnosed as a primary medullary basal-celled carcinoma
of the appendix, most probably arising from the epithelium of the
crypts. The well-known resemblance of the basal-celled carcinomas
of the skin to the endotheliomata might easily explain the diagnosis of
sarcoma and endothelioma made by some writers of primary appen-
diceal neoplasms manifestly of the same histologic type as the tutnor
. here described. Out of the forty-two cases of primary malignant
diseases of the appendix, collected by Rolleston and Jones, thirty-seven
were described as carcinoma, three as endothelioma and two as sarcoma.
Of the thirty-seven cases diagnosed as carcinoma seventeen appear to
be of the spheroidal-celled type to which our case belongs, six were
transitional from the columnar-celled type to the spheroidal celled, six
of a columnar-celled type, while eight cases were described merely as
**carcinoma."

As the descriptions of the cases of endothelioma and sarcoma might
be interpreted also as dealing with a basal-celled carcinoma, it seems
very probable that all the cases of primary malignant disease of the
appendix so far reported fall into two classes of carcinoma: (i) the
columnar-celled type, as found in stomach, intestine, et cetera; and (2)
a peculiar spheroidal-celled type closely resembling the basal-celled
carcinoma of the skin. In the latter class Rolleston and Jones would
place the great majority of the primary cases of appendiceal carcinoma,
and as it is very likely that the cases described as endothelioma and
sarcoma were in reality this form of carcinoma, I think it is very prob-
able that the vast majority of the reported cases of primary malignant
tumors of the appendix are to be classed as basal-celled carcinomas.

This view is borne out by the age incidence. The average age of
the cases described as columnar-celled carcinoma of the appendix is
fifty-two years, in general corresponding with the average age of
primary carcinoma of the intestine. The individual character of the
other forms of appendiceal carcinoma is shown by the early age inci-
dence, it being shown by Rolleston and Jones to be 30.6, 30.3 and 39
years for the cases described as carcinoma, endothelioma and sarcoma
respectively. Of fourteen cases described as spheroidal-celled carci-
noma the average age was only 24.2 years. The basal-celled carcinoma
of the appendix is, therefore, a disease of early adult life, the earliest
observed case being at twelve years.

The peculiar character of this neoplasm is also shown by its rela-
tively slight malignancy. In thirty-three of the cases collected by
Rolleston and Jones the appendix was removed during life, but the
nature of the disease had not been suspected in any case before the
operation. This, in the majority of cases, consisted simply in the
removal of the apendix. In three cases a portion of the cecum at the
base of the appendix was removed and in two other cases a more radical

PRIMARY CARCINOMA OF THE APPENDIX.

549

operation was necessary. In the majority of cases recovery is definitely
stated to have occurred. The basal-celled form does not tend to set up
metastases or to recur after operation.

In the case of the columnar-celled type the prognosis is not favor-
able. This fact is only another evidence of the importance of basing

FIGURE II — HIGH POWER VIEW OF A PORTION OF SAME, SHOWING THE NESTS OF

SPHEROIDAL CELLS.

the ultimate diagnosis and prognosis upon the precise histologic variety
of the neoplasm. To the average practitioner the terms carcinoma and
sarcoma convey a more or less hopeless prognosis. The pathologist
engaged in practical diagnosis should, therefore, specify the precise
histologic variety of neoplasm examined and call attention to the vary-
ing degrees of malignancy according to type, location, et cetera. In
basal-celled carcinoma of the appendix a good prognosis may be given,
in other forms a bad one.

560 ORIGINAL ARTICLES.

Of the etiology of this peculiar type of appendiceal carcinoma, we
have, of course, no definite knowledge. In the thirt>'-three cases from
whom the appendix was removed during life, the courses leading to the
operation were symptoms of appendicitis in twenty-seven cases, salpin-
gitis in three cases, retroversion of the uterus in one case and iliac
fistula in two cases. Letulle and Weinberg, as well as other writers,
have urged the etiologic relationship between chronic inflammation
and the development of appendiceal carcinoma. As in our case, it is
difficult or impossible to establish any definite relationship between the
co-existing conditions. A number of observations made during our
routine diagnostic examinations lead me to think that here, as in other
regions of the body, there may be more than one factor in the develop-
ment of these neoplasms of the appendix. It is not at all uncommon to
find in appendices showing chronic ulcerative or obliterative changes
with healinjg and epithelial regeneration portions of the mucosa of glands
constricted off by newly-formed connective tissue. In the obliteration
of the lumen remains of glands are not infrequently seen completely
isolated from the mucosa of the patent portion of the lumen by dense
connective tissue. The lumen may occasionally be divided into two
canals by a band of granulation tissue extending across it, or blind
tubes lined by columnar cells may be found in the submucosa and some-
times extending into the muscularis and subserosa. Such inflam-
matory constrictions and snarings-off may^ involve a single gland or a
large portion of the mucosa. Iq these isolated epithelial s-tructures
there are sometimes seen evidences of proliferation, and the writer has
observed such isolated gland-spaces completely filled with polyhedral or
spheroidal cells suggesting the earliest stage of carcinoma development.
In the great majority of cases, however, the columnar cell type is
preserved and the glands become cystic or undergo atrophy. The
occurrence of such atypical epithelial cell-nests as the result of the
healing process might be taken as strong evidence of the inflammatory
origin of appendiceal carcinoma. One other observation by the writer
suggests, however, still another possible mode of origpin. In the sub-
serosa and outer muscular layer of an appendix taken from a case of
chronic purulent salpingitis of gonorrheal origin, there were found
two atypical epithelial structures consisting of spaces filled with poly-
hedral or spheroidal cells but with a periphery of low columnar cells
set upon a definite basement membrane. There was no evidence of the
existence of malignant disease in any part of the body, and these epi-
thelial structures could not be regarded as metastases. If not metas-
tatic there was also no reason to regard them as the result of an inflam-
matory snaring-off from the mucosa, as such inflammatory changes
were not present. The most probable interpretation of this finding,
is, I think, that of a congenital anomaly or malformation, the two
entirely separate and isolated epithelial structures representing aberrant
epithelium due to some disturbance of development. From such aber-
rant epithelium a carcinoma could develop here as in other regions of

ANN ARBOR MEDICAL CLUB. 661

the body. Our general knowledge of congenital malformations of the
appendix is not great, but a double lumen has been observed, and the
observation given above may represent a minor degree of this anomaly.

It has been suggested recently that primary carcinoma of the appen-
dix probably plays an important part in the origin of carcinoma of the
cecum. I think this is doubtful in so far as the basal-celled variety is
concerned, and thds form, as has been shown, is by far the most com-
mon neoplasm of the appendix. The columnar-celled type may play
such a role.

In conclusion, the great majority of primary neoplasms of the
appendix represent a specific type of carcinoma corresponding histo-
logically to the basal-celled carcinomas of the skin, and are relatively of
slight malignancy, having little tendency to metastasis and recurrence
after operation. While not common, their rarity is evidently exag-
gerated. They occur most frequently in early life — before the fortieth
year. A good prognosis may be given in cases of this type. Their
etiology is to be referred to a neoplasia occurring in epithelium snared
off during the process of repair in chronic appendicitis, or to a neoplasia
of aberrant epithelium in the wall of the appendix.

Ann Arbor, Michigan, Ferdon Road.

TRANSACTIONS.

ANN ARBOR MEDICAL CLUB.

STATED MEETING, NOVEMBER 22, 1906.

The Vice-President, CHARLES W. EDMUNDS, M. D., in the Chair.
Reported by JOHN WILLIAM KEATING, M. D., Secretary.

READING OF PAPERS.

OPSOJSr/NS.

Doctor Ernest B. Bradley^ of New York City, read a paper on
this subject. (See page 536.)

Doctor Vaughan : I want to compliment Doctor Bradley, and
especially the audience, for having so excellent a presentation of this
subject. It is as clear and concise and plain a statement of Wright's
work as I have seen anywhere. The beauty of Wright's work lies in
his technic. He is, as Doctor Bradley has said, a wizard in his work.
The beauty of it lies in the fact that he is giving his mixtures, the
so-called vaccines, with some means of knowing what their effects are.
Much harm has been done by injecting all kinds of things into the
human body and the animal body. I think it is exceedingly interesting
because it shows how stupid man is after all. For twenty years here in
our own hygienic laboratory, and it is the same elsewhere, we have
known that an animal once having an injection of any kind was not a
safe animal to make a second experiment upon ; and for twenty years

562 ORIGINAL ARTICLES.

we have kept animals that have been used once for such experiments in
rooms or cages marked, "Used Animals," so that if anybody made a
second experiment upon them he would know that the results would
not be altogether reliable. And still we have not understood it. You
are aware of the fact that after the administration of diphtheria anti-
toxin it sometimes happens that very serious results follow and that in
some cases the child has died very suddenly. Pericherk collected, about
a year ago, all the cases he could find and he learned that ill effects
followed the second injection, and whether ill effects followed or not
depended upon the time that elapsed between the first and second injec-
tions. I noticed this fifteen years ago in the treatment of tuberculosis
with nuclein and came very near killing a number. A man would come
around and get an injection and then not come again for a number of
days and the second injection would be likely to affect him very seri-
ously. About six or eight months ago Rosenau and Anderson took up
the question to find out whether there is anything in the diphtheria
antitoxin that is poisonous or not, and they have made a very valuable
contribution to our knowledge on the subject. They found that if one
injects into the abdominal cavity under the skin or into the blood a
small or large amount of horse's serum, and waits ten days after the
first injection and then makes a second injection, it will kill; the animal
dies in thirty minutes. It has difficulty of respiration, convulsions,
partial paralysis of the posterior extremities, and dies from failure of
respiration, while his heart continues to beat for some minutes.

This is very closely related with work we have been doing in our
laboratory. If you take egg albumen and inject any amount of it into
the abdominal cavity of a guinea pig or rabbit it will produce no bad
effect upon the animal. If you wait ten days and then give the animal
another injection of egg albumen it will kill him in thirty minutes ; but
you can give the injections day by day and it will not kill. Or, you can
take a drop of milk and inject it into the peritoneal cavity of a guinea
pig, or ten cubic centimeters, and you get no effect, but if you wait ten
days and put five cubic centimeters in again it will kill him. For the
last ten or fifteen years we have been putting all kinds of mixtures of
bacteria into people without any control. The beauty of Wright's work
is that he keeps a check upon the effect of his injections. This is splen-
did work and sooner or later it will be explained and we will know
scientifically how to treat infectious diseases.

When I think of the men who are at work on this and learn about
their results, whether they call them opsonins, aggressins, antitoxins,
or agglutinins, I have to think of men, particularly the uneducated man
who goes into a chemical laboratory and picks up this bottle and that
bottle and mixes the contents without knowing anything about chemis-
try, and gets a change in color and then runs off and reports what he
has done. I am not decrying this kind of work, it has got to be done ;
but they are simply cutting, as it were, here and there, trying to tmravel

ANN ARBOR MEDICAL CLUB. 563

a tangled skein. Some man in the dim and distant future — not so far
distant, I believe — will get hold of the right thread and the whole thing
will be plain, whether it is called opsonin, agglutinin, aggressin, anti-
toxin, lysin, no matter what the name. Again I congratulate the audi-
ence upon the presentation of this interesting subject.

Doctor Dock : I can only repeat Doctor Vaughan's congratulations
to the speaker and audience for hearing this excellent address. As
Doctor Vaughan says, it is one of the clearest and most satisfactory
expressions of the subject I have come across; and it is especially
important because we have been fortunate to get here this evening a
large number of men who in the next couple of years ought to be work-
ing on this subject. The young doctor with great advantage to himself
and with great advantage to science can devote himself to it. The
work is difficult and requires pains, but that it can be mastered compar-
atively easily we have been able to see in the work of one of our senior
students, Mr. Walker. Unfortunately it is true that much of this will
be detail work, but undoubtedly the complete relations will be cleared
up in time. The glamour, too, will fall away from it ; miraculous cures
will not be so frequent, but that great practical and scientific gains will
follow, I have no doubt.

Mr. Walker : I am much interested in this subject, and would like
to present some of the work I have done in order to see what Doctor
Bradley thinks about it. First, Doctor Bradley states that the number
of bacteria taken up in suspension would depend on the number of
bacteria put in. My work seems to show that is not the case ; beyond a
certain limit there is no variation, or so little that it can be accounted
for by incidental overlapping. That is quite reasonable when we think
that the opsonin represents a definite amount of certain bodies in the
blood, and if one or more take hold of each bacterium, and there are
not enough bacteria put in to take up all the opsonin we would get a
lesser phagocytosis ; but, if we put in enough to take up all the opsonin,
then no matter how many more we put in we would not get a greater
phagocytosis. Second, about the opsonic index. Doctor Bradley states
that the phagocytosis observed in several preparations is proportional
directly to the opsonic content of the sera tested. My work shows that
is not quite the case ; for higher opsonic values of sera the phagocytosis
observed is less than a direct proportion indicates. I made my tests by
making up artificial sera, by diluting normal serum once, twice, three,
and four times, and the results I got showed that for higher values of
sera the phagocytosis was far less than what we would be led to expect.
Using the opsonic index, we get indications of change in opsonic power,
but we will not get accurate results if my work is right. Some time ago
we made other experiments which seem to bear that out, and corrob-
orate it, and it would be interesting to hear what Doctor Bradley would
say about it.

Doctor Georg : I wish to thank Doctor Bradlev for the clear dem-

554 ORIGINAL ARTICLES.

onstration of Wright *s method of working on an old substance and
giving old things new names. I think those of us who were in practice
when Koch first announced, a year in advance, that he had something
that would cure tuberculosis, ver>' well remember the terrible misery in
which that announcement was afterwards written on the pages of Ger-
man literature. The trouble with Koch's tuberculin was that the dose
was overreached in the start, the same now as Wright shows in the
negative phase of the index. We had the negative index and continued
to work under the negative index until Mrchow called attention to the
dire results that were following, tuberculosis taking a form more viru-
lent than seen for many years, and the thing was dropped, but not
entirely. Some men in Germany continued to work and saw that the
dose had been overreached, and where Koch worked with a milligram,
they worked with one-five-hundredth of a milligram and saw beautiful
results in certain cases. Of course at that time this was work that
could not be understood. This was the first phase of using a germ to
produce a cure of the disease that is caused by the same germ. Now
the work has gone into new channels. Antitoxins have long been
known as weapons of offence and defence produced by the organism
after the injection of bacteria. It is a product of the living cell in com-
bat against poison that has been introduced. It is a method of defence
of the system against attack. The antitoxin is not formed until the
toxin accumulates. Investigators have shown that bacteria make their
attacks in several lines, and for each line the normal organism responds
with a new weapon of defence, that is, provided the normal powers of
reaction are yet equal, to the occasion. Another point in regard to this
is, that when these bodies are produced in an animal and taken out in
pure form and reintroduced as vaccine, they stimulate the s\"stem enor-
mously more for reproducing this kind than the bacteria at first did
and without the danger of the bacteria and the products. This is the
present state of knowledge : that this antitoxin is produced and this is
injected and used for therapeutic measures instead of bacteria or dead
bacteria or any extract of bacilli ; for, mind you, the dead bacteria con-
tain many poisons that are thrown off ; the toxin poison that only comes
into the system after the bacilli die and the body is digested, resulting
in general toxemia under which the organism finally succumbs when
its resistance has been overcome.

At the Tuberculosis Congress held at The Hague, Netherlands, last
September, Professor Maragliano, of Genoa, read a resume of his
work on the specific treatment of tuberculosis, tracing this work during
the last fifteen years. First it was observed that living bacilli, and also
the bodies of dead bacilli, when introduced experimentally into animal
organism were followed by the production of specific protective bodies.
These bodies were later demonstrated as antitoxic, bacteriolytic, and
agglutinins, each body a distinct specific weapon of defence and offence
against the invasion. These antitubercular substances are obtained

ANN ARBOR MEDICAL CLUB. 556

when the injected poison (bacilli) is small in quantity and produces no
toxic conditions, but when tuberculosis is developed and infection
spreads, then these protective bodies diminish in quantity. These anti-
tubercular boddes are produced by the healthy organism always in the
same method of defence against the various bacillary substances and
toxins. Living bacilli are not needed for the production of antibodies
useful for treatment of the disease, and the injection of antitubercular
bodies is followed by the further production of these substances. Mar-
agliano proves that there is absolutely no danger in the use of his anti-
tubercular preparation consisting of definite quantities of antitoxic,
bacteriolytic, and agglutinating substance.

In Italy these antitubercular serums have now been in use in the
practice of physicians for ten years, and according to Maragliano, with
positive curative results when the injections are given before the disease
has endied in structural changes of the lungs, for then antitubercular
bodies cannot undo the ravages of tubercle bacilli any more than quin-
ine can cure a chronic interstitial hepatitis or deep seated changes in the
spleen, both the result of the malaria Plasmodium, itself easily destroyed
by quinine. These injections are now made directly into the lung tissue.
In localized tuberculosis the injections are always followed by positive
cures — a restoration of the tissues to normal conditions. Maragliano's
work is a decade in advance of the much heralded cures of tuberculosis
by Professor Behring, and I consider it high time that the profession
in America were furnished with these antitubercular serums by Amer-
ican bacteriologic manufacturers. All that we have so far is the watery
extract of tubercle bacilli, a dangerous product which needs an opsonic
index for guidance.

From the physician's standpoint, whatever good there is in Wright's
opsonic index becomes inaccessible, for it needs the constant super-
vision of the bacteriologist, and, be it remembered, he uses a toxin not
an antitoxin, and it depends entirely on the condition of the system
whether the result will be positive or negative. With the prepared
antibody the system always receives much needed help in its fight with
the enemy even when general toxemia from mixed infection has already
taken place, a time when any further injection of toxins adds greatly
to the disadvantage of the fighting organism.

Maragliano demands that the diagnosis must be made before the
microscope reveals the bacilli in sputa, for that denotes already broken-
down tissue, a cavity, however small, has formed. A focus can form
in an apex and cause for a time no more general symptoms than if
located around the knee-joint. This is already an advanced time for
beginning with the injections, but to wait still longer, until larger cav-
ities have formed and general toxemia has taken place and the entire
organism is at the point of collapsing, then we have a state of things
very complicated and you cannot expect to get a medicine to cure a
case of cavities of the lung, restoring the tissue to the normal condition
— that could not be expected.

656 ORIGINAL ARTICLES.

Doctor Hutchins: I have been interested in this question of
opsonins and all of Wright's work, and have attempted to do some work
with it in a practical way. I have succeeded in producing the vaccine,
but have not done enough work to be justified in giving any conclu-
sions. The so-called Tr tuberculin of Koch is difficult to procure in this
country, and Wright uses only one kind, which is made in Germany,
and it is hard to obtain it. As Doctor Nancrede said a moment ago,
this sounds too good to be true. Some reports published are most
encouraging. The Boston Medical and Surgical Journal, of October
2y, cites a number of cases of tuberculosis of the lungs. In one case
tuberculin injections were used more as a prophylactic measure. The
patient had no cough or physical signs, but was given tuberculin and
the opsonic index was lowered for the tubercle germ; then the index
increased. The patient gained in weight and the general health
improved. One of the most striking cases reported is that of a woman,
thirty-nine years old, confined to bed with hectic fever and consolida-
tion of the right apex. She lost w^eight and yielded sputum in which
considerable numbers of tubercle bacilli were found. She was given
injections of tuberculin and after some months the physical signs were
negative; the cough disappeared. She gained nineteen pounds in
weight, considered herself cured, and went about her usual employment.

Another phase requires more confirmation than obtains at present.
I Vobably you all know that Doyen, in Paris, claimed to have discovered
the germ that produces cancer, the micrococcus neoformans. Doyan did
not possess the best reputation as a scientific man, but he wrote a book
and produced a serum which he claimed cured carcinoma. This caused
so much comment that the French Cabinet of Surgery investigated it
and came to the conclusion that the serum was worthless. It was also
investigated by others and they arrived at the same conclusion. In the
London Lancet, of the 7th of April, appears an abstract of a paper
read before the Belgian Health Association, giving an account of an
experimenter who took this serum, heated it to 60^ for an hour, cooled
it, and injected small amounts into patients. He found that if after the
first injection a positive phase was obtained there was no chance of
curing the carcinoma, but if the phase was negative, and in a number
of cases this was accomplished, the tumors decreased in size. For
example, in a case of carcinoma of the uterus, inoperable, by following
this treatment for a considerable length of time, the carcinoma was
diminished in size, the patient operated upon and all tissue removed.
You see what this means.* It is not claimed that carcinoma can be
cured with any vaccine ; but if in inoperable carcinoma the glands can
be reduced so that the surgeon can take them out, the effect is some-
thing tremendous. This is only one phase of the work and must be .
confirmed before proper estimate can be made of its value. But another
line of work can be undetaken, namely, that of measuring the phago-
cytic power of the blood resistance to infection. We can begin to

CLINICAL SOCIETY. 567

realize what can be done if we succeed in increasing the general resist-
ance before undertaking an operation. Suppose a patient is to have an
abdominal operation, and something can be administered in the evening
to increase resistance so that when he wakens next morning he is in
better condition to operate — what a great gain it would be. This is
only suggestive, but there are great possibilities in it for someone to
work out.

Doctor Charles W. Edmunds : One of the greatest obstacles is
the development of the technic. For four months, working every day,
Doctor Bradley was simply learning how to perform the technic. In
order to save time, Doctor Bradley will give a demonstration tomorrow
in Doctor Dock's clinic.

Doctor Bradley: Doctor Walker has asked two questions: first,
about the number of bacteria taken up being limited in the serum. We
have never found it so. But the staphylococci differ so in appearance ;
one stain will take up such an amount that you cannot count them ; and
if you take one that is virulent that would not take them up at all.
About the dilution, I cannot answer that. A Baltimore worker has
gotten results that are the opposite of ours. About the treatment of
cancer, I remember of reading it and wondering how much immunity
would result, because it is beyond belief, it seems to me. I did not
know about these newer cases that Doctor Hutchins reports. Doctor
Wright has suggested the advisability of inoculating in advance of
operations, especially on the mouth and nose, raising the index to 1.8
or 1.4 so that the danger of infection would not be quite so great. If
that can be done it would be well. I do not know whether it can or not.

CLINICAL SOCIETY OF THE UNIVERSITY OF MICHIGAN.

STATED MEETING, DECEMBER 12, 1906.

The President, HUGO A. FREUND, M. D., in the Chair.
• Reported by DAVID M. KANE, M. D., Secretary.

REPORTS OF CASES.

SPECIMEN FROM A CASE OF ANEURYSM OF THE ARCH OF THE
AORTA RUPTURING INTO THE LEFT BRONCHUS.

Doctor Dock: I wish to present this specimen which came from
a patient who was in the hospital just a year ago. The case illustrates
the class of aneurysms which may produce very few signs and still be
capable of detection. The man did not come on account of symptoms,
but being in the hospital with his sick wife sought the clinic on account
of slight shortness of breath.

On examination by Doctor Morris it was found that the patient, a
man of forty-nine years, had an inequality of the pupils, a fact of
interest in connection with the existence of aneurysm, but negative in
this case as it had existed for twenty years. Physical examination at
first showed no other abnormality than weak vesicular breathing and

558 ORIGINAL ARTICLES.

weak vocal fremitus on the left side while the patient was lying down,
becoming stronger on sitting up. This fact, however, led to the sus-
picion of aneurysm or other tumor pressing on the bronchus, and
further examination showed a tracheal tug and delayed pulse in the
left radial. The skiagraph revealed a great enlargement in the region
of the arch of the aorta and the fluoroscope showed that this under-
went pulsation synchronous with the pulse. A diagnosis was accord-
ingly made of aneurysm involving the whole arch of the aorta and
pressing on the left bronchus.

The patient was put on potassium iodid and given directions regard-
ing mode of life. He lived without notable symptoms until the end of
November, when he was taken with grip, which was soon followed by
signs of pneumonia of the left lower lobe. From the beginning there
was a good deal of blood in the' sputum, but the symptoms subsided
and the patient seemed to be doing well until at the end of two weeks,
when he sat up in bed, had a copious hemorrhage and died within two
minutes.

Through the efforts of the attending physician. Doctor Shumaker,
of Butler, Indiana, an autopsy was made and the sp^imen forwarded.
This shows a dilatation of the whole arch of the aorta from just above
the valves to a point about the same level in the thoracic part. The
arch is uniformly and considerably dilated, the -wall thin and exceed-
ingly calcified in thin plates. The innominate is also dilated. In the
posterior part of the descending arch the wall is torn where it was
closely adherent to the vertebra. At the bottom of the arch is a large
old clot, partly adherent, and beneath this an opening, about a centi-
meter in diameter, leading into the left bronchus. The thickening of
the mucosa around the opening suggests that there was pressure there
for some time.

The case is esix?cially interesting in connection with the other intra-
thoracic tumors we have had recently in the hoispital, and especially
one in the ward now, where there is a very similar skiagraphic picture.
But in this latter, one of secondary carcinoma, we have the picture of
venous pressure, in contrast to the obstruction of the bronchus in the
present case, and also in contrast to the neuralgic pain so prominent in
another woman recently in the ward.

A CASE OF SYDENHAM'S CHOREA.

Doctor Theophil Klingmann : The case I am about to describe
and demonstrate presents two interesting features. First, that the
patient exhibits himself when the incoordinate movements are no longer
constant and appear only when voluntary effort is attempted; and
second, that this phase of the disease has been more prolonged than
usual.

The history contemplates a man, aged twenty-six, American, civil
engineer, single. His parents are both living and well, and the family
history is negative except that one brother had two attacks of rheu-

CLINICAL SOCIETY. 569

matic fever and father had spinal meningitis. Both made good
recovery.

The patient was admitted to the University Hospital, September 21,
1906. He was healthy as a child, suffering only from the usual diseases
of childhood. Seven years ago he had an attack of rheumatic fever
from which he made complete recovery. He remained well until
December, 1905, when he suffered from a severe attack of tonsillitis,
and within a few days of the onset of this affection he developed pain,
swelling, and redness in the wrists, elbows, knees and ankle-joints.
The diagnosis of rheumatic fever was made by the attending physician.
During a period of several weeks he had marked elevation of tempera-
ture with occasional remissions. His physician stated that it was
of a typhoid character but patient exhibited no positive evidence of this.
He also stated that his heart was affected. The patient was confined
to bed for six months, and became much emaciated and exhausted. For
a short time he had some difficulty in swallowing. He developed two
bed sores the size of a dollar in the sacral region. After the fever sub-
sided he began to have involuntary incorordinate movements of the
hands, arms, feet and legs which were so marked that it was impossible
to take the patient's pulse at the wrist or to take the temperature in the
axilla. The movements continued for several weeks and then gradu-
ally subsided but reoccurred whenever the patient made voluntary
efforts. There was some mental enfeeblement.

At the time of my first examination, September 26, 1906, I found
the patient well-nourished, musculature well-developed, and absence
of atrophy. There were marked irregular incoordinate movements in
the hands, arms, feet and legs brought on by intentional effort and
subsiding a few moments after the patient became quiet. There was
muscular weakness in the upper and lower extremities and inability to
maintain steady contraction. The dynamometer registered 37 in the right
and 39 in the left hand. He was easily exhausted and the difficulty
increased by prolonged intentional effort. The gait was not ataxic but
unsteady. There was much interference with standing and walking,
owing to the spasmodic movements. Romberg's sign was not present.
Knee-jerks slightly increased, ankle-jerks normal, no clonus, no Babin-
ski reflex. With the exception of a slightly delayed sense of touch on
the outer side of both feet, there were no sensory disturbances. No
disturbance was observable in the perception and judgment of active
movements of the extremities. The organic reflexes were normal. The
cranial nerves were not involved. There was a systolic murmur, with
greatest intensity at the apex. The patient was quiet and unemotional,
he presents no mental characteristics, psychic stigmata, nor sensory
stigmata. The eye examination made by Doctor Parker showed but a
slight contraction of visual fields, no inversion of color-fields, and
nothing characteristic of psychoneurosis.

After observing the patient for some time it became evident that the

560 ORIGINAL ARTICLES.

possibility of an organic lesion could be eliminated and I made the
diagnosis of Sydenham's chorea based upon the following facts :

(i) The irregular, unwilled but conscious movements in the upper
and lower extremities.

(2) Inability to maintain steady contraction of the muscles of the
upper and lower extremities.

(3) The actual loss of power in the muscles involved.

(4) The association of these symptoms with arthritis and possibly
endocarditis.

Hysteria being so closely allied to chorea, the possibility of this
condition must not be overlooked. Hysteric patients occasionally suffer
from general spasmodic movements which may resemble those of true
chorea. A patient suffering from chorea may also suffer from hysteria,
but in the absence of all the characteristic stigmata of the latter, the
irregularity of the incoordinate movements and the escort of attending
s>Tnptoms in the former differentiate the conditions.

About ten days ago the patient devieloped an acute condition. He
had a temperature of 101.5°, sore throat and a general soreness in the
shoulders, back and extremities, respiration was very rapid, pulse
weak and rapid. This all subsided within a few days.

PROBABLE HEPATIC CANCER.

Doctor Don D. Knapp : A man, aged forty-eight, farmer, German.
There is no history of previous trouble in any way bearing on present
disease. On Christmas, 1905, patient had feeling of fulness after
eating and then would wake up at night to find sour-tasting mucus run-
ning from his mouth, which at times contained food particles. He also
vomited at times. In latter part of February he called on physician
because of feeling of fulness in stomach and abdomen, with dull pain
in these regions, sharper at times, and radiating to back and shoulders.
Patient vomited after nearly every meal that summer and lost twenty
pounds in weight. In September he was told by a physician that his
liver was enlarged.

Patient entered hospital in this condition December 5, 1906. On
physicial examination, the abdomen was found two fingers' breadth
above level of ensiform in epigastrium and somewhat lower at level of
umbilicus. About four fingers' breadt below level of navel the fulness *
sloped away rather abruptly. The upper right quadrant was somewhat
fuller than the left. On deep inspiration, the epigastrium raised four
fingers* breadth above the level of ensiform. On the right about half
way between umbilicus and ensiform there was a small elevation which
descended about one and one-half inches on deep breathing. On palpa-
tion, the abdominal wall was thin and moderately lax. There were no
painful points. A firm resistant mass filled the right side as far down as
the crest of the ilium in the anterior axillary line. In the median line,
its lower margin was about one and one-half inches below navel, and
on the left it extended upward and outward to meet rib margin at

CIJNICAL SOCIETY. 661

about nipple line. The surface was hard, smooth, and covered with
rounded elevations with depressions. The lower edge was rounded and
regular, feeling slightly nodular on right. The mass descended one
and one-half inches on deep inspiration. No fluctuation could be
detected in the abdomen nor was edema present in the extremities.

Rectal examination showed a small soft prostate. On inflation of
colon the abdomen became fuller below the mass rising high up in
front below the navel and covering the mass for a distance of two
inches. The distension pushed the liver up one inch. The lower edge
was not palpable. Stomach distension showed fulness and tympany
below mass in median line and to left. On inserting the needle for
aspiration into one of the elevated masses the top of the tumor felt as
hard as tendon for about one-eighth inch, nipping needle very tightly ;
beyond the tissue was firm, resembling liver in consistency. There
was nothing obtained on aspiration.

Occult blood was found in the stools at ever>'^ examination.

Blood: Hemoglobin, sixty per cent; white cells, 8,000; red cells,
2,760,000.

Stomach examination revealed absence of free hydrochloric acid.
Total acidity averaged about 20. Streptothrix were present in large
numbers, mucus in excess,, a few small blood clots, and no pepsin.
Some hypermotility was also present.

With the previous history of the case and the nature of the tumor,
carcinoma or gumma are the most probable. A history of syphilis is
entirely lacking. A carcinoma on the other hand may be primary in
the liver — a rare occurrence, or secondary to carcinoma of the stomach
or gall-bladder.

MASTOIDITIS AND FURUNCULOSIS IN EXTERNAL AUDITORY MEATUS,

Doctor Marshall L. Cushman : I wish to present two cases, not
on account of their rarity but rather because of their frequent occur-
rence, and the fact that the diflFerential diagnosis between them is
often attended with some difficulty. Each of these cases presents the
typical signs and symptoms of their condition, but nevertheless in each
case was there made a wrong diagnosis by the attending physician.

Case L — ^A German, male, age thirty-eight, comes to clinic on
account of pain and swelling "in left ear." Trouble began three months
ago with an earache which "gathered and broke," discharging on and
oflF until one week ago, when pain increased, discharge stopped, and
swelling appeared behind ear. Patient complains of some buzzing and
deafness, thickness of lips and stiflFness of left side of face.

Examination showed the following:

Left ear, — Membrane red and bulging, some drooping of posterior
and superior canal wall in the depth. Signs of old perforation in
membrane. Canal dry, no pus present. Auricle prominent and post-
auricular fold obliterated. Some edema over mastoid and tenderness

562 ORIGINAL ARTICLES.

for radius of about two inches behind canal, especially marked above.
Temperature and pulse normal. Leucocytes, io,i8o.

HEARING TEST.

Right ear. Left ear,

10/21 Voice 1^/35

Weber +

— Rinne —

normal High notes normal

normal Low notes normal

Case II. — An American, female, age twenty-three, comes to clinic
with diagnosis of acute mastoiditis. Two weeks ago patient had pain
in left ear which was very severe. She was somewhat dizzy and once
lost consciousness and fell to floor. The condition was diagnosed as
acute suppurative otitis media. The ear began to discharge and con-
tinued to do so for two days, during which time pain was absent or ver>^
slight. The discharge stopped four days ago but returned this morn-
ing. During first attack there was some postauricular swelling.

Examination showed the left ear more prominent. The area of
tense swelling is in region of mastoid tip, which is red and tender to
pressure. Tragus tender to pressure. No tenderness over antrum and
no obliteration of postauricular fold. Canal narrowed by swelling of
superior, posterior, and inferior walls. Probe enters floor and passes
through periosteum to bare bone in region of middle ear. Pus in open-
ing. Membrane red, thickened, not bulging and covered with creamy
pus. No drooping of posterosuperior canal wall at fundus. Leu-
cocytes, 15,000. Temperature and pulse normal.

]

HEARING TESl.

ight ear.

Left ear.

normal

Voice

10/21

Weber

Rinne

normal

High notes

normal

Low notes

normal

Here, then, we have two cases that present points of marked sim-
ilarity, a careful examination, however, easily diflferentiating them, the
former being, of course, an acute mastoiditis, and the latter a furuncle
of the external canal.

Both cases were operated upon and made uneventful recoveries with
the exception that in the former case a slight eczema auris occurred
which promptly disappeared upon changing from iodoform to plain
gauze dressings.

The facial paralysis in the former case well illustrates one type that
is occasionally seen, that resulting probably from pressure incident to
the increased tension in the t>inpanum present during the middle ear
suppuration.

CLINICAL SOCIETY. 563

TUMORS OF THE BRAIN,

Doctor Barrett: I wish to demonstrate four specimens of gross
lesions of the brain.

The first is a large gliomatous tumor filling the greater part of the
white substance of the posterior part of the right frontal lobe, its pos-
terior limits just touching the region of the internal capsule. The
specimen i^ from a woman about fifty-four years old, who five months
before death had a sudden paralysis of the left arm which soon passed
away, but a day later there came a complete left-sided hemiplegia of a
spastic type. Some of the symptoms present and the circumstances
under which they developed, namely, coming on immediately after a
visit to a friend who was paralyzed, made the diagnosis of hysterical
paralysis probable. The later course of the disease made the diagnosis
of a tumor of the brain quite certain. During the last months the
patient was stuporous and the left arm and leg were rigid and their
muscles were considerably atrophied. Examination of the eyes showed
double optic neuritis.

The second specimen is a gumma of the dura mater of the right
frontal region> with intimate adhesions to the brain tissue and infil-
tration of the surrounding region. A second gumma is located in the
region of the right amygdaloid nucleus. The case is that of a man
seventy-five years of age, who showed a deep disturbance of conscious-
ness, with unclear perceptions, complete disorientation and episodes of
motor excitement. The only symptoms noted which indicated a brain
tumor were several attacks of explosive vomiting, occurring during the
last weeks before death.

The third specimen is a large endothelioma of the dura mater. The
tumor is as large as a hen's ^%% and evid-ently sprang from the dura in
the region of the sella turcica. It is from a man who at about the age of
fifty gradually lost his eyesight from optic atrophy. From this time on
there was a gradually progressing dementia, accompanied by peculiar
sensory disturbances, such as a feeling of worms crawling over his
body. On a number of occasions he had epileptiform convulsions.
Shortly before death there was a marked edema of the eyelids. There
were no localizing symptoms and the tumor was not diagnosed.

The fourth specimen is from a woman, who at the age of five
years, during typhoid fever, had an attack of complete right-sided
hemiplegia. In later years she learned to use the right leg a little
but otherwise the paralysis was complete. There were athetoid move-
ments of the left hand. She never developed intellectually, and often
had epileptiform convulsions. She died at the age of nineteen. The
brain showed the region of the central convolutions of the right hemi-
sphere, collapsed inward. Only the upper two centimeters of the two
central convolutions were uninvolved. Sections through the hemis-
phere show no trace of the fibers of the internal capsule, and in the
gross preparation it seems as if the entire left pyramid is absent.

564 ORIGINAL ABSTRACTS.

AURAL VERTIGO,

Doctor Jeanne C. Solis: I wish to present briefly this evening a
report of two cases of vertigo interesting from several standpoints.

Case L — This is a man, aged sixty-three years. Four years ago he
had la grippe, and he has had some rheumatism in the past. His pres-
ent trouble began four years ago. It consists of dizzy spells in which
he is faint and weak. These spells have lately grown more frequent.
They occur most often when he is quiet, either when lying in bed,
sitting quietly, or driving. He thinks lately his memory is failing, and
he feels very nervous and depressed over the occurrence of these attacks.

C(ise 11. — The patient here was sixty-six years old. He gives a
history of having had la grippe every year since it came to the country.
The present trouble came on last August. At this time he began to
have dizzy spells with ringing in the right ear. These dizzy spells were
preceded by paresthesias of numbness and queer feelings in the distri-
bution of the right fifth nerve beginning on the face and running back
towards the neck. Patient feels on the verge of dizziness all the time.

Both patients feared severe brain disturbance.

The examination of the patients showed nothing in the nervous nor
general condition to account for their dizziness or vertigo, but in both
cases impacted cerumen was discovered in both ears, the removal of
which relieved the distressing symptom of vertigo.

Doctor James F. Breakey read a paper on "Lupus Vulgaris."
(See next issue).

EDITORIAL COMMENT.

WILLIAM JAMES HERDMAN, Ph. B., M. D., LL. D.

Young's expression that "Death loves a shining mark, a signal
blow," is truly exemplified in the demise of Doctor Herdman. This
eminent physician died in Baltimore, Maryland, December 14, and was
buried in Ann Arbor, Michigan, on the 17th. He had just been
granted a year's leave of absence from the University of Michigan to
pursue special study abroad and with his family was en route to the
coast when stricken with intestinal obstruction which necessitated
surgical procedure in Baltimore.

Doctor Herdman was bom in Concord, Ohio, September 7, 1848,
and descended from Scotch-Irish ancestry. His literary education was
acquired at Westminster College, Pennsylvania, and at the University
of Michigan, the degree of Bachelor of Philosophy being received from
the latter institution in 1872 and that of Doctor of Medicine in 1875.
In 1897 the University of Nashville conferred upon him the honorary
degree of Doctor of Laws. Since receiving his medical degree he has

DOCTOR WILLIAM JAMES HERDMAN. 665

been a continuous member of the teaching force of the University of
Michigan, serving in various connections : — Demonstrator of Anatomy,
1875-1890; Lecturer on Pathologic Anatomy, 1879-1880; Assistant
Professor of Pathologic Anatomy, 1880-1882; Professor of Practical
and Pathologic Anatomy, 1882- 1888; Professor of Practical Anatomy
and Diseases of the Nervous System, 1888-1890; Professor of Nervous
Diseases and Electrotherapeutics, 1890-1898; Professor of Diseases of
the Mind and Nervous System, and of Electrotherapeutics, 1898 to the
time of his death. Special lectures in the Department of Law have
likewise been given by him for many years. In addition to services
rendered in the capacities already cited he held the Professorship of
Orthopedic Surgery in the Northwestern (Toledo) Medical College,
1882- 1887, during which time he was Consulting Surgeon to Saint
Vincent's Hospital ; and Surgeon-ip-Chief of the Ann Arbor Railroad,
1887-1902, being reappointed to that position in 1905.

The doctor has been continuously engaged in the practice of medi-
cine 'since the date of his graduation, and has been the recipient of
many honors in medical organization: — Chairman of the Executive
Committee of the American Medical Association, 1897- 1899; Chair-
man of the Section on Neurology and Medical Jurisprudence, 1896;
Expresident of the American Electrotherapeutic Association ; Exmem-
ber of the Council of the American Academy of Medicine ; Councilor
of the First District of the Michigan State Medical Society, 1905-1906.
He was indeed a valued member of local, state, and national medical
organizations.

Doctor Herdman has contributed much toward demonstrating that
insanity is a disease. The Psychopathic Hospital at the University of
Michigan is a monument which bespeaks his untiring effort to establish
a detention hospital wherein the study of incipient cases might be
prosecuted with a view to determining their curability before consign-
ing them to institutions for the hopelessly insane. The doctor has
conducted considerable scientific research work concerning the bearing
of electricity on the growth of man and animal, and was mainly instru-
mental in establishing at the University of Michigan the first electro-
therapeutic laboratory in this country. He was the author of several
text-books and papers on educational, medical and electrical subjects.

Doctor Herdman was married to Nancy Bradley Thomas on Sep-
tember 16, 1873, and she, together with three children — Doctor Elliott
K., Marie L., and Anna M. — survive him. As a physician, deceased
was eminently capable and enjoyed a large clientele. As a teacher, he
was thorough and progressive. As a man, he was the embodiment of
a Christian character, broad intellect, and dignified bearing. Since
1877 he has been a ruling elder in the Presbyterian Church, and
testimony harmonizing with his long religious profession was rendered
on the occasion of a recent illness when he said to a visiting clergyman
— "I believe in prayer anrl si (^o you. Let us pray.''

566 EDITORIAL COMMENT.

ANNOTATIONS.

OBLIGATIVE ANAEROBES CULTIVATED IN THE PRES-
ENCE OF OXYGEN.

The ordinary convenient classification of microorganisms Ento
aerobes and anaerobes bids fair to receive relegation to obscurity if the
recent disclosures of European investigators are verified by subsequent
experimentation. Torozzi and Wrzosek have apparently demonstrated
the possibility of cultivating obligative anaerobic bacteria in the pres-
ence of oxygen. Acting in accordance with the ideas of these two men
Harrass devised a culture medium which produced luxurious colonies
of anaerobes in the free presence of the gas which was supposed to
absolutely inhibit their development. Torozzi and Wrzosek obtained
excellent results by adding to a broth medium a small piece of animal
organ, such as liver, kidney, spleen or lymph tissue. Harrass, how-
ever, utilized only liver tissue in his experiments. After grinding one
pound of fresh calf's liver in a sausage machine, he mixed it with one
litre of water in which one per cent of peptone or glucose had been dis-
solved. The medium was rendered neutral and consigned to Erlen-
meyer flasks after which it was subjected to live steam sterilization for
a period of from one and one-half to two hours. A solid medium
productive of the above result has not yet been evolved, but Harrass is
sanguine that his effort to discover one will yet be successful.

MEDICAL INVESTIGATION OF THE PESTIFEROUS

MOSQUITO.

While, the role of the mosquito in the causation of disease has not
been accurately determined, experimentation has disclosed the fact
that a definite part is played by the pest in producing malarial and
yellow fevers, the Anopheles and Stegomyia respectively being the
agents of transmission. Smith, who has long been engaged in the
study of mosquitoes, has recently contributed the result of his findings
to medical literature. The connection of Stegomyia fasciata with
yellow fever is confirmed by the discoveries of the American Commis-
sion at Havana, 1900-1902; of Doctor Juan Guiteras, 1901-1902; of
Doctors Ribas and Lutz at Sao Paulo, 1903; of the representatives of
the United States Marine Hospital Service at Vera Cruz, 1903-1904;
and of the French Commission at Rio Janeiro, 1903. Subsequent cru-
sades against the pest at Havana, Vera Cruz, and Rio Janeiro, resulted
in the complete eradication of the disease. Most careful observation
in excellently equipped laboratories has resulted in failure to determine
the parasite of yellow fever in the body of the insect. However, several
animal parasites have apparently been demonstrated by the French
Commission, but these are thought by Smith to be merely undigested
food particles. While yellow fever has prevailed at Rio Janeiro for

HYPNOTISM. 667

years, Petropolis, only thirty miles distant, is entirely free from the
scourge. This is explainable in the fact that the city is situate at a
high altitude, a condition unfavorable to mosquito development under
ordinary conditions. Stegomyia fasciata thrives best and is most active
at a temperature of from 80** to 86** Fahrenheit. At 60° it is sluggish
and at 56° is almost entirely inactive. However, the insect has been
kept at a temperature as low as 30° for a period of from twelve to
twenty-four hours without death. Thermal conditions likewise exert
marked influence on the reproductive function, a reasonably warm
'atmosphere and a meal of blood being essential to the female before the
deposition of eggs, which usually is accomplished in the water, between
' twenty-five and one hundred fifty being laid at one time. Stegomyia is
not migratory, but readily adjusts itself to circumstances, and for this
reason its destruction is rendered more difficult.

CONTEMPORARY.

HYPNOTISM: ITS HISTORY, NATURE, AND USE.

[HAROLD M. HATS, OF THB COLLBGB OF PHYSICIANS AND SURGEONS, NEW YORK CITY, IN^THB POPULAR

SCIENCE MONTHLY.]

( Continued from page S22)

We have already found the primary cause of the sleep when pro-
duced by the tiring of the eyes. The eyelids droop because the muscles
become temporarily paralyzed. There is one advantage in placing the
hand on top of the head. It is that it rolls the eyeballs upward, thus
putting them in a natural position for sleep. The various other pro-
cesses after the sleep has been produced are all dependent on the
workings of the nervous system. Let us first try to explain the cata-
leptic state — how it is that the arm becomes so rigid that the bones can
be broken before the arm will bend.. The most plausible explanation
to my mind is that impulses are sent from the brain which make one
set of muscles counteract the influence of another set. For example,
let us say that two men of equal strength are pulling with all their
might on a thick stick. As long as the pull is the same on both sides,
the stick won't move. How the mind can exert such an influence we
do not know. The same idea of the counteraction of various muscles
applies to the whole body as well as to one arm. Yet some one may
ask how these muscles can have the power to stand more strain than
they do in the waking state. It is only that as our normal selves we
never use our full muscle power. This is because not enough stimula-
tion is ever given to the muscle to make it work to its full extent. But
in cases of great excitement or danger, even the weakest seem to have
superhuman strength.

The loss of the sense of pain or anesthesia can also be accounted
for by the brain. When we say we have a pain in our finger, we don't

568 EDITORIAL COMMENT.

really mean that. The cut is in the finger, but the pain is in the brain,
and consciousness is necessary for us to have pain. Suppose a man is
going to have an operation on his finger and is made unconscious. Now
the finger is there, but the pain has disappeared, showing that pain is
not located in various parts of the body, but in the domain of con-
sciousness. So if, under hypnotic influence, you tell the patient that he
will have no pain, he thinks the pain away, so to speak — ^knocks it out
of his consciousness.

How we can run needles into people and produce no blood seems
still more remarkable, but physiologically it can be explained. Let me
say here that if any one should pierce a large artery with a needle,
serious consequences might result. Let us say that we penetrate the
skin in a place where there are thousands of little capillaries. Each
one of these vessels is connected with the nervous system by two sets
of nerve fibers — those which can dilate the vessels, those which can
constrict them. Now, suppose I give the suggestion that I am going
to run a needle through a certain part of the arm. An impulse, sent
from the brain, constricts the blood-vessels at this spot, inhibits the
sense of pain, and the needle comes out again without a drop of blood
following it.

The explanation of the dizziness from water supposed to be whiskey
and the cure by salt supposed to be sugar is that both are the result of
an unexplainable force whereby the patient takes every word of the
hypnotizer as gospel, though it is contradictory to his own ideas. For
example, in one case a patient told me that he knew the glass con-
tained water and yet it tasted like whiskey, and he also knew that the
sellar contained salt and yet it tasted like sugar.

The cure of the finger-nail habit and all the post-hypnotic sugges-
tions may be summed up briefly. All we should do is to refer back to
the perfect or subjective mind where all these suggestions are stored
up and say that the objective mind draws nutriment from it, and in this
nutriment these .suggestions given under the hypnotic influence come
into play.

Before closing this portion of the essay I should like to say that I
believe hypnotism is not an occult power, but is a simple, natural
physiological process. And again, anybody can use the power just as
any one can become a good piano player, or student or business man
by training. Yet it is only those with the natural tendency toward
personal power who will make the greatest success.

It would indeed be pleasing to me to cite a number of wonderful
cases where hypnotism has been used experimentally in order to show
the great influence of the mind over the body — how a horse can be
ridden over the outstretched body of a man in a cataleptic state, how
illusions and hallucinations can be produced, how we may even obtain
negative hallucinations, how we can turn an adult into a child, how we
can conjure before the mind's eye vistas grand and suberb, panoramas
gorgeous and elegant, how the commonest man may become an orator,

HYPNOTISM. 569

a saint, an assassin perhaps. But all these things would be far beyond
the scope of this essay. However, ^ne case seems to be of especial
interest as it shows how far hypnotism may be used in the cure of
various inflammations.

The experiment is on a nurse twenty-eight years old, who is not at
all hysterical. She is the daughter of plain country people, and has
been for a long time an attendant in the Zurich Lunatic Asylum, which
Forel directs. He thinks her a capable honest person, in no way inclined
to deceit. The experiments were as follows: A gummed label was
fixed upon her chest on either side ; the paper was square. In no case
was an irritating gum used. At midday Forel suggested that a blister
had been put on the left side ; and at 6 o'clock in the evening a moist
spot had appeared in that place ; the skin was swollen and red around
it, and a little inflammation also appeared on the right side, but much
less. Forel then did away with the suggestion. On the next day there
was a scab on the left side. Forel had not watched the nurse between
noon and 6 o'clock, but had suggested that she could not scratch her-
self. The other nurses said that the subject could not raise her hand
to her chest, but made vain attempts to scratch. Forel repeated the
experiment later ; he put on the paper at 1 1 145 a. m. and ordered the
formation of blisters in two and one-half hours. Little pain was sug-
gested, and the nurse therefore complained but little. At 2 o'clock Forel
looked at the paper on the left side, for which the suggestion had been
made, and saw around it a large swelling and reddening of the skin.
The paper could with difficulty be removed. A moist surface of epider-'
mis was then visible, exactly square like the paper. There was nothing
particular under the paper on the right side. Forel then suggested the
disappearance of the pain, inflammation, et cetera.

In time everything disappeared.

Many investigators have been able to bring about a change in blood
supply and other visceral changes of a similar kind. Changes in tem-
perature have been made as much as three degrees centigrade. Bern-
heim found that by suggestion he could induce local reddening of the
skin. This is undoubtedly a vasomotor change. These local red spots
were often found in the middle ages on the hands of monks and nuns
after they had been looking steadily at a cross for hours. At that time
it was supposed to be a miracle and a message from the Divinity. In
i860, a woman was found with these spots or blisters caused by some-
thing unknown. It was learpied that she got these while in the hyp-
notic state. The wounds healed in the normal way and all that remained
to make it necessary for it to be commented upon, was that it gave
the investigators the idea of trying to produce these spots by artificial
means. Kraift-Ebing, a noted German physician, produced certain
results analogous to those cited above. He would put something in
the patient's hand and give him the suggestion that it was burning. A
reddening would appear. He would, take a scissors, a piece of metal

670 EDITORIAL COMMENT.

and a postage stamp (saying it was a mustard plaster) and would
produce the same results.

Wonderful as it may seem — that hypnotic suggestion can produce
such grave organic changes — the physician has only to reflect for a
moment on the powerful changes which the mind exerts over the course
of a disease. He realizes only too well that the mental attitude of the
patient toward his malady is of almost as much importance in the cure
as the therapeutic measures he may advise. Processes of inflammation
are purely physiological in the light of modern medicine, and yet there
can be no inflammatory process which cannot be made worse by con-
centrated mental worry. A sore finger to the phlegmatic individual is
a trifle ; but the hysterical woman makes a "mountain out of a mole hill"
of it and thereby actually makes the inflammation .worse.

THE USES OF HYPNOTISM.

The general tendency has been in the last decade to use hypnotism
indiscriminately ; but like every therapeutic agent, it in time will become
restricted and only used in certain complaints. It surely should be
included by every physician in his "therapeutic arsenal." It has one
thing in its favor which places it above all remedial agents, and that is,
that when it is used properly it can do no harm. We must recognize
that in all the scientific literature on the subject, there has not a single
death been reported from its use. The unscientific application is its
abuse.

We must also recognize that there are many cases that are prac-
tically incurable by medical treatment, cases which defy the greatest
physicians, cases which are surprising because of their persistency.
When the last extreme has been reached, when physicians consult and
pronounce the case as practically incurable, hypnotism may be tried.

Before the advent of ether or chloroform, the possibility of using
hypnotism for anesthetic purposes was thought of, and apparently its
use in this direction met with success in a limited number of cases. In
1459, Doctor Guerineau announced that he had amputated a thigh under
hypnotic anesthesia. Some other reports are as follows : Jules Cloquent
amputated a breast in 1845; Doctor Loysel of Cherbourg ampu-
tated a leg and removed some glands in 1846; a double amputation of
the legs by Doctors Fan ton and Toswel in 1845 ; amputation of an arm
by Doctor Joly in 1845 ; and in 1847 a tumor of the jaw was removed
by Doctors Ribaud and Kiaro of Potiers — all under hypnotic anesthesia
(Bernheim's "Suggestive Therapeutics").

But hypnotism was found to have more drawbacks than advantages
in these cases of major surgery. In the first place, hypnotic anesthesia
is a difficult state to produce and even a more difficult state to maintain.
Secondly, there is always the possibility of the patient awakening
unexpectedly and dying from the shock of the operation.

Although it has thus fallen out of use as an anesthetic in these
serious cases, still it is used constantly, and more and more every day.

COMPILATION OF CENTENARIANS. 571

in minor surgery. In dentistry it certainly has its place ; in out-patient
departments of our hospitals it is often of value, as it has no after
effects.

The various medical cases that have been treated by the hypnotic
method are too numerous to recount. They include nearly every form
of mental nonequilibrium and also cases of general organic trouble
dependent more or less on the mental attitude of the patient. They
include habits of various kinds, such as onycophagie or finger-nail
biting, excessive smoking, dypsomania, nervous twitchings, et cetera,
nervous headaches, insomnia and neuralgias ; chronic nervous constipa-
tion and diarrhoea and dyspepsia ; local and general pain, insomnia and
neurasthenia. Nor is this all. Hypnotism's greatest blessing consists
in the cure of psychic paralytics and psychic hysterics. In this connec-
tion we may say that it should be used unconditionally. Doctor Starr,
in a lecture at the College of Physicians and Surgeons, cited a case of
paralysis in the left arm from the shoulder to the elbow. A physician
knows that it is impossible to get a true paralysis of this kind. Doctor
Starr hypnotized the patient in his clinic and in less than three minutes
the arm was in as good working order as ever. During the course of
the past year, I have worked on a few hysterical cases for physicians
where nothing but hypnotism could cure them. A remarkable case of
true organic nature came to my notice over a year ago. A lady had a
severe swelling on her finger which was so painful that I could hardly
bandage it for her. I put her to sleep, suggested the pain away, told
her the inflammation would subside the next day and awakened her. I
could then do anything I wished to the finger without hurting her.

I have left aside the part that hypnotism plays in mental and moral
culture — a phase of the subject so vast that it deserves more consider-
ation than could be given here.

[the end.]

MEDICAL NEWS.

A COMPILATION OF CENTENARIANS.
Statisticians have been busy in Europe compiling longevity tables
of the various countries. Germany, with a population of 55,000,000,
has but seventy-eight persons who have passed the century mark.
France, which is generally accredited as being a land of luxury and fast
living, has 213 centenarians in a population of 40,000,000. England
has 146, Scotland 46, Denmark 2, Belgium 5, Sweden 10, Norway 23,
and Spain 410. The most striking figures emanate from the land of
the Balkans where, notwithstanding the stormy scenes of insurrection
which are constantly enacted, persons past the hundred year mark are
not uncommon. Servia has 573, Roumania 1084, and Bulgaria 3883,
a centenarian for every one hundred of its population.

572 MEDICAL NEWS.

MINOR INTELLIGENCE.

Carelessness of parents for their offspring is responsible for death
by suffocation of over two thousand infants annually in England, six
hundred dying from this cause in London alone.

Report from Europe announces the publication of a newspaper
under the direct business and editorial control of the inmates of the
new asylum for the insane at Maueroeling, Austria.

The Fulton (Missouri) Hospital for the Insane has recently been
awarded damages to the extent of $14,000 for destruction wrought dur-
ing the Civil War. The institution's claim was for $41,000.

Haakon Bjoinstern is the cognomen of a young giant who
recently arrived in this country from Norway. He measures seven
feet six inches in height, and contemplates the pursuit of farming in the
far west.

Doctor Lapponi, physician to the Pope, died in Rome, of pneu-
monia, on December 7, 1906. The doctor has long been a sufferer from
cancer of the stomach and in his weakened condition was unable to
withstand the ravages of pneumonia.

Doctor William Osler, Regius Professor of Medicine at Oxford,
arrived in Baltimore on December 8, en route to Toronto to participate
in his mother's one hundredth birthday. According to the dictum of
the doctor his mission would seem to be forty years too late.

France is agitating the abolition of the death penalty for capital
crimes. At a meeting of the cabinet on October 30, a measure to this
effect was presented, and it is highly probable that the Chamber of
Deputies will pass a law in accordance with the desire.

Antwerp will be the scene of an international exposition during
April, May, and June, 1907. While the exhibits will be of a general
nature, embodying art, manufacture, et cetera, the medical profession
will be represented in departments of hygiene and pharmacology.

The United States Bureau of Entomology has changed the name
of the Stegomyia fasciata, the transmitter of yellow fever, to Stego-
myia calopus. The change was made to obviate confusion, the old
name, fasciata, being commonly applied to another insect of the same
group.

New York City is to have a new public bath at 242-248 East Fifty-
fourth street. Plans for a building three stories high, equipped with
gymnasium appliances and nmning track, have been filed with the
building department. The entire cost of structure and equipment will
be $200,000.

The sale of absinthe has been prohibited in the canton of Vaud,
Switzerland, and it is probable that the other cantons will pass like laws.
The baneful effects of the drug are manifest in France, and in all proba-
bility the Swiss mandate was passed to preserve the country from the
plight of France.

MINOR INTELLIGENCE. 573

On October 5 the Tri-State Medical Society, comprising the states
of Tennessee, Alabama, and Georgia, relinquished its charter and
became; an integral part of the newly organized Southern Medical
Association, which includes Alabama, Georgia, Florida, Louisiana,
Mississippi and Tennessee.

Doctor E. Symes-Thompson, consulting surgeon to the famous
Brompton Hospital for Consumptives, died recently in London at the
age of sixty-nine. The doctor was a distinguished authority on tuber-
culosis, as was likewise his father. He was one of the projectors of the
institution with which he was connected.

Doctor John A. Ou^hterlony, a prominent physician of Louis-
ville, who died last year, bequeathed the major portion of his estate as
a fund to establish a tuberculosis hospital in that city. The sum stipu-
lated was $100,000, and although the will was contested by relatives a
compromise still renders the hospital possible.

New York City is to have a society for the suppression of unneces-
sary noise, which is declared a menace to public health and general
comfort. The organization is the conception of a woman, and the
initial advisory board comprises Doctor Thomas Darlington, Doctor
Charles L. Dana, and Doctor John W. Brannan.

Doctor William K. Otis, professor of genitourinary diseases in
the New York School of Clinical Medicine, died recently at his home in
New York City, of pneumonia. He was a son of Doctor Fessenden N.
Otis, the distinguished genitourologist, and was graduated from the
New York College of Physicians and Surgeons in 1885.

On November 5 Madame Curie delivered her first lecture as pro-
fessor of physics at the Sorbonne, Paris, her subject being ionization.
The ampitheatre was crowded and the ovation accorded the first woman
occupant of the chair so teremendous that the Madame was overcome
with emotion. Her husband has been dead less than a year.

A lecture recently delivered before the Paris Academy of Medi-
cine by Baron Henry Rothchild, M. D., discloses many conditions
hitherto unkonwn regarding the dissemination of disease by means of
Oriental rugs. It is claimed that upon the demise of a wealthy Moslem
his body is wrapped in his most valuable rug and transported by camel
to Mecca. Upon interment the rug is abandoned and members of the
caravan, seizing the opportunity for gain, barter through Oriental
bazaars for sale to Occidental people.

The magnificent building of the Manhattan Eye, Ear, Nose, and
Throat Hospital, on Sixty- fourth street. New York City, was opened
on October 30, 1906, with appropriate ceremony. The building is
situate on a plot of four city lots. It is seven stories in height, and
has a frontage of seventy-five feet and a depth of one hundred feet,
being erected at a total expenditure, inclusive of equipment and site,
oi $700,000. The material is brick with white sandstone trimmings
and the structure is fireproof throughout.

574 MEDICAL NEWS.

A NEW field is being opened for women qualified for nursing. The
managers of liners plying the Atlantic have become cc^izaat of the
usefulness of trained nurses on board steamships. Two graduate nurses
of a New York hospital were recently tendered positions with the Ham-
burg-American Line, and it is likely that the other lines will follow the
example.

A FEATURE of the One hundred twenty-fifth annual meeting of the
Massachusetts Medical Society was the amendment of a resolution
affecting the admission of practitioners of sectarian medicine to the
guild. This question has long been a bone of contention in the society
and after much discussion the last meeting v^as productive of a com-
promise whereby homeopaths are henceforth eligible to membership.

Considered from a lucrative standpoint veterinary surgery is
apparently on the wane, a condition that is ascribed to the automobile
industry. The president of the London Royal College of Veteri-
nary Surgeons is authority for the statement that within three
years London will aflFord a field for only three hundred veterinarians,
whereas in the past the services of six thousand have been required.

The demise of three centenarians has recently been announced by
contemporaries. Mrs. Margaret Holmes, of Berlin, New Hampshire —
the mother of twenty-one children — at the reputed age of one hundred
two; Reverend William Howe, of Cambridge, Massachusetts, at the
age of one hundred one ; and Mrs. Ann Betts, of East Orange, New
Jersey, on the eve of her one hundred third birthday which she was
preparing to celebrate.

Doctor William P. Buck, of Landsdowne, Pennsylvania, reports
the birth of an infant at six and one^half months, whose weight was
one pound and three ounces. It was immediately placed in a crude
incubator made of a box and heated with water bottles. Until the
mother's milk appeared the babe was fed on sugar water. However,
after two weeks on human milk it gained four pounds, and its chances
for living seem excellent.

Doctor Alonzo Garcelon, one of the oldest members of the
American medical profession, died at his home in Maine, December 8,
at the age of ninety-three. Doctor Garcelon graduated from the (Cin-
cinnati) Medical College of Ohio in 1839 and in 1853 became a mem-
ber of the American Medical Association. He was one of the organi-
zation's most faithful constituents and it is reported that until last year
he was never absent from a meeting.

Immeasurable benefit is being derived from the public gardens of
the Civic Club in Philadelphia. At a recent meeting of this organi-
zation a report of the work accomplished during the past summer dis-
closed that over 500,000 children had visited the grounds, an average
daily attendance of 12,000. That the children may be permitted greater
recreation in the open, the committee is considering the advisability of
granting access throughout the year.

MINOR INTELLIGENCE. 575

A CRUSADE against the white plague is being stringently prosecuted
by the American Antituberculosis League. An agitation is rife which
contemplates the introduction of bills, for the uniform regulation of
indigent consumptive persons and for the prophylaxis of the disease,
into the legislature of every state. The next meeting of the League
will be held at Atlantic City in June, 1907, under the presidency of
Doctor George Brown, of Atlanta, Georgia.

Beginning with the January, 1907, number, The Journal of the
Association of Military Surgeons of the United States will be known as
The Military Surgeon, retaining the old name as a subsidiary title.
This publication, which is under the editorial charge of Doctor James
Evelyn Pilcher, is the pioneer military medical journal in the English
language and is deserving of the support of all physicians engaged in
the practice of military medicine and surgery.

The psychic effect upon children of the much-abused funny page
supplement of our Sunday newspapers, has received consideration from
the editor of the Alienist and Neurologist. All these creations he rele-
gates to the domain of lunacy, and suggests that the moral influence
of the pictures is far from elevating. Such imaginative effects as Foxy
Grandpa and the Katzenjammer Kids seem calculated to inspire in
youngsters irreverence and disrespect for adults.

The Mississippi Valley Medical Association held its annual meet-
ing at Hot Springs, Arkansas, November 6, 7, and 8, 1906. It was
voted to offer a prize of one hundred dollars to the members of the
association presenting the best essay recording some original research
work in the Mississippi Valley. A committee of three was appointed
to formulate rules for the contest, which will be announced later. The
next meeting will be held at Columbus, Ohio, some time during
October, 1907.

RECENT LITERATURE.

REVIEWS.

PULMONARY TUBERCULOSIS.*

The great increase of interest in tuberculosis has resulted chiefly in
efforts at prevention or treatment on a large scale. At the same time
there is still a very decided need of greater knowledge and more care
in the study of individual patients, with special reference to early diag-
nosis, and there is also a very great need for clearer ideas regarding
treatment. For this reason such a book as the one under consideration
forms a welcome addition to medkal literature. Doctor Francine
writes clearly and with accurate knowledge. He speaks briefly of the
patholog) , but especially and in detail of the treatment of pulmonary

676 RECENT LITERATURE.

tuberculosis, considering all the essentials, such as rest, fresh air, exer-
cise, climate, diet, the various specific and symptomatic methods of
treatment and hints and helps to patients. The volume concludes with
a chapter on the methods of study and treatment at the Phipps Institute.
Those who have not yet obtained a book covering these lines cannot
dio better than read this work, the convenient size and clear type of
which add to the pleasure of its perusal. The proofreading shows
some marks of haste, as "toulase" for "tulase," "Van Ruck'' for "von
Ruck," et cetera.

♦Its Modern and Specialized Treatment, with a brief account of the
methods of study and treatment at the Henry Phipps Institute of Phila-
delphia. By Albert Philip Francine, A. M. (Harvard), M. D.
(University of Pennsylvania), of the Staff of the Henry Phipps Insti-
tute, Philadelphia; Examining Physician to the White Haven Sana-
torium ; Instructor in Medicine and Physician to the Medical Dispen-
sary of the University of Pennsylvania ; Medical Registrar to the Phila-
delphia Hospital. Illustrated. J. B. Lippincott Company, Philadel-
phia and London.

THE PHYSICIAN'S VISITING LIST FOR 1907.*

This Visiting List is arranged in different styles to record from
twenty-five to one hundred patients a week. The volume is well bound
in flexible leather, and contains ready information on several subjects,
such as antidotes for poisons, doses of drugs, methods of resuscitating
the asphyxiated, et cetera. It also contains pages for recording
addresses, and keeping records of deaths and births. Its former stan-
dard of excellence has been maintained for the issue of 1907.

D. L. p.

♦Fifty-sixth year of Publication. The Dose-Table is revised in
accordance with the new United States Pharmacopeia (1900). Phila-
delphia: P. Blakiston's Son & Company. Price, $1.00 to $2.25.

PROGRESSIVE MEDICINE.*

"Progressive Medicine" for December, 1906, has just reached us.
This volume contains all the latest work that has been done on the fol-
lowing subjects : Diseases of the Digestive Tract and Allied Organs —
Liver, Pancreas, and Peritoneum ; Genitourinary Diseases ; Diseases of
the Kidneys ; Anesthetics ; Fractures ; Dislocations ; Amputations : Sur-
gery of the Extremities ; Orthopedics ; and Practical Therapeutic Ref-
erendum.

We have commented upon the value of this work so many times
that it hardly seems necessary to say more. We feel justified in recom-
mending it to our readers who are interested in the advancement of
modern knowledge.

*By H. A. Hare, M. D. Lea Brothers & Co.

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